Presentation on theme: "BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS"— Presentation transcript:
1 BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS DR. A. AKHATOR FWACS, FICSSENIOR LECTURER DELSUCONSULTANT SURGEON DELSUTH
2 PRE-TEST Breast cancer is the most common cancer in women in Nigeria Breast cancer is the most common cause of cancer related deathsBreast cancer commonly present as painful breast lumpPrognosis of breast cancer is related to the size of the breast tumorTrastuzumab (HerceptinR) is treatment for ER/PR positive tumor
3 LEARNING OBJECTIVESRealize the burden of breast cancer in our environmentThe importance of early diagnosis in management of breast cancerEvaluate breast cancer symptoms and recommend appropriate management
7 INTRODUCTION Breast cancer – malignant neoplasm arising in the breast. Most common cancer in women worldwide.Incidence in Nigeria is 33/100,000Incidence in males 1-9% of casesPeak age 42 years78% locally advanced disease22% metastatic disease
8 THE FACTS ABOUT BREAST CANCER APPROXIMATELY EVERY 3 MINUTES A WOMAN IS DIAGNOSED WITH BREAST CANCERAPPROXIMATELY EVERY 12 MINUTES A WOMAN DIES FROM BREAST CANCERINCIDENCE INCREASING 5%/YEAR IN DEVELOPING COUNTRIESA REVIEW 1991 – 33% ADVANCED DISEASE IN DEVELOPED COUNTRIES2007 – 60-80% ADVANCED DISEASE IN DEVELOPING COUNTRIES
9 MORE FACTS IN THE UK 2009 IN US INCIDENCE – 128.6/100,000 POPULATION NEW CASES - 38,212 FEMALES, 250 MALESSECOND COMMONEST CANCER DEATHSIN US211, 240 NEW CASES EXPECTED IN WOMEN1,690 NEW CASES IN MENAfrican-American women have a lower incidence but higher mortalityThey also have higher risk for triple-negative tumoursINCIDENCE – 128.6/100,000 POPULATIONLife time risk of 1 in 8 women
10 Factors that increase risk LifestyleFamily HistoryPersonal History
11 Family HistoryMother, sister, or daughter has developed breast cancer before menopause 3 x.If two or more close relatives (e.g., cousins, aunts, grandmothers) have/had breast cancer.Mutations in genes BRCA1 and BRCA2 increase one's susceptibility to breast cancer.
12 FAMILY HISTORY SHARED GENETIC MAKEUP SHARED LIFESTYLE SIMILAR ENVIRONMENTAL EXPOSURE5-10% CAUSED BY INHERITED GENETICS
13 PERSONAL HISTORY Previous history of breast cancer Previous history of benign breast diseaseMenarche <12 yearsHormonal contraceptives – current and recent usersNulliparaFirst delivery after 30 yearsMenopause at 55 years or olderHormonal Replacement Therapy
14 LifestyleSeveral studies found a lower incidence of breast cancer among women who exercise regularlyHigher proportion of breast cancer among obese women.Smoking
15 OTHER LIFESTYLE FACTORS ALCOHOL – one or more drinks a day increases riskDIET – High in fruits and vegetables decreases riskEXERCISE – Regular exercise decreases riskWEIGHT – Maintaining healthy weight decreases risk
16 ENVIRONMENTAL RISKPOLYCYCLIC AROMATIC HYDROCARBONS – Chemicals produced when coal, oil, gas, garbage are burnt – increases riskSMOKING – Passive smoking increases risk; when smoking started as teenagerELECTROMAGNETIC FIELD – NO RISK
17 BREAST CANCER MYTHS SHAMPOO – NOT TRUE WEARING BRA – NOT TRUE PUTTING MONEY IN BRA – NOT TRUERADIATION FROM CELL PHONES – NOT TRUEANTIPERSPERANTS/DEODORANTS – NOT TRUEBREASTFEEDING GRANDCHILDREN – NOT TRUEWITCHES INFLICT – NOT TRUE
18 CLASSIFICATION Heterogeneous disease at each stage Early breast cancer (Tis-2/N0-1)In situ diseaseInvasiveLate breast cancer (T3,4/N2/M1)Locally advancedMetastatic disease
19 STAGE GROUPING STAGE 0 – Tis, N0,M0 STAGE IA – T1, N0,M0 STAGE 1B – T0 or T1, N1mi, M0STAGE IIA – T0 or T1, N1, M0; T2,N0,M0STAGE IIB – T2, N1, M0; T3, N0, M0STAGE IIIA – T0 to T2, N2, M0; T3, N1 orN2,M0STAGE IIIB – T4,N0-N2,M0;STAGE IIIC – any T, N3, M0STAGE IV – any T, any N, M1
20 In Situ Carcinoma * 15–30 Invasive Carcinoma 70–85 Total Cancers Per CentIn Situ Carcinoma *15–30Ductal carcinoma in situ, DCIS80Lobular carcinoma in situ, LCIS20Invasive Carcinoma70–85No special type carcinoma ("ductal")79Lobular carcinoma10Tubular/cribriform carcinoma (Better prognosis than average)6Mucinous (colloid) carcinoma (Better prognosis than average)2Medullary carcinoma (Better prognosis than average)Papillary carcinoma1Metaplastic carcinoma, (Squamous)
21 EARLY DIAGNOSIS ….. Early diagnosis leads to better prognosis The size of the tumor and extend of spread determines the prognosisEarly stageBetter possibility for cureLess morbidityLess toxic treatment
22 PROGNOSIS Overall survival/Disease free interval Quality of life Adverse effect/toxicity of treatmentBody habitusPsychological
23 PROGNOSTIC FACTORS Age Tumor size Axillary LN status Histological gradeReceptor status – ER, PRHER2-neu(C-erb B2)
24 OVERALL SURVIVAL CURE RATES FOR BREAST CANCER 5 year cure rates of >90% obtainable for early tumours,< 30% for late tumours
25 SURVIVAL RATES BY STAGE Stage I – 88%Stage IIA – 81%Stage IIB – 74%Stage IIIA – 67%Stage IIIB – 41%Stage IIIC – 49%Stage IV – 15%
26 QUALITY OF LIFE Scars of treatment/no breast Younger survivors face Emotional stressesTrouble with social functioningChemotherapy induced early menopauseSexual difficulties
29 Advantages of BSE It is simple and easy to perform. It is convenient and requires little time.It is private.It involves no medical costIt is safe and non-invasive.It requires no specific equipment.
30 Methods of training Pamphlets and leaflets. Instructional videos. Demonstrations and personal instructions.
31 Breast-self-examination Breast self examination – monthlyUnderstand the breast and look for changesDevelopment of a lump.Swelling.Skin irritation or dimpling.Nipple pain or retraction.Redness or scaliness of the nipple or breast skin.Discharge - other than milk.Standing and lying
32 When to do a Breast Self-Exam The best time to do breast self-exam is right after her period, when breasts are not tender or swollen. If she does not have regular periods or sometimes skip a month, do it on the same day every month.
33 Clinical Breast Examination BREAST EXAM BY DOCTOR (CBE) – EVERY 3 YRS BETWEEN 20-39YRS;YEARLY AFTER 40YRS, before mammogramPOOR SENSITIVITY - 54%HIGH SPECIFITY – 94%CBE-detected tumours has 70% survival
34 Mammogram XRAY OF THE BREAST (MAMMOGRAM) – YEARLY AFTER 40 YRS Mammography-detected tumours has 90% survivalMammography increased detection of DCIS from 1% to 21%Regular screening by mammography and CBE decrease mortality by 25 – 30% in women 50years or older
35 EARLY DIAGNOSIS TRIPLE ASSESSMENT CLINICAL EVALUATION IMAGING HISTOCYTOLOGY
36 CLINICAL EVALUATION History Physical examination Progression of symptomsRisk factors for breast cancerTreatment to datePhysical examinationLocalsystemic
37 FEATURES OF BREAST CANCER Breast lumps – painlessSwelling of the breastNipple discharge – blood stainedRetraction of the nippleChanges in the skin of the breastBreast or nipple painSigns of spread
52 MASTECTOMY - Indications Large tumorsCentrally located tumorsLarge tumors cf size of breastMulticentric tumor – mammogramPrevious radiotherapyPatient’s preference
53 MASTECTOMY Simple mastectomy + SLND Skin-sparing mastectomy Nipple-sparing mastectomyModified Radical mastectomyBreast reconstruction/breast formRadiotherapy after mastectomyLarge tumors 5cm or largerDeep seated tumors4 or more positive lymph nodes
54 Breast conservation surgery BCS + RT = BCT75% Px in developed countriesTumor control rate of 80-90%5 year survival rate – 70-88%Local recurrence rate 2-10%Without RT – 15-40%TYPES OF BCSLumpectomyWLEQUART
55 CONTRAINDICATION TO BCT Very small breastVery large breastAdvanced/high grade diseaseLactating breast/pregnancyMulticentric diseaseContralateral diseasePrevious RTCentral tumorsMultiple tumorsRisk for 2nd tumor
56 BCS WITHOUT RADIOTHERAPY BCS is considered without radiotherapy if all of the following are presentPatients aged 70 years or olderTumor is <2cm and has been completely excisedTumor is hormone receptor positive and patient is placed on hormone therapyNo positive axillary lymph node
57 CHEMOTHERAPY Combination, sequential therapy Adjuvant/neoadjuvant settingCMFCAF; AC, TACCapacitabineCommon side effectsHair lossNausea and vomitingFatigueStomatitisAnorexiaIncreased susceptibility to infectionsOthers – menstrual, heart, hand and foot syndrome, neuropathy, bladder
60 EARLY BREAST CANCER DCIS – BCS with 2mm margin Pagets disease – BCS + removal of nipple- areolar complexInvasive disease – BCS + SLN biopsy/ mastectomyStart adjuvant chemotherapy or radiotherapy as soon as clinically possible within 31 days of completion of surgery.Endocrine therapy – Tamoxifen – premenopausal; aromatase inhibitor for post menopausal
61 ADVANCED BREAST CANCER MastectomyPrimary/adjuvant systemic therapyBiological Rx - trastuzamabUncontrolled local disease – wound managementPain managementLymphedemaCancer related fatigueBone metastasisBrain metastasis
62 BREAST CANCER IN WARRI142 new cases presented to breast clinic ( )20 Were Breast Cancer (14.08%)ONLY 1 CAME WITH EARLY DISEASE (5%)62% PRESENT > 3 months after noticing symptomsWHY ARE THEY COMING LATE?
63 WHY ARE THEY COMING LATE IgnoranceLack of facilitiesFear of diagnosisFear of the treatmentAlternative treatment optionsDelay in referrals from peripheral centresNO SCREENING PROGRAM
68 WAY FORWARDNMA – active in promoting awareness of cancer especially breast cancerNHIS – Include cancer screening as part of their healthcare provisionProvision of facilities – radiotherapyShort trigger for referral of breast complaints
69 TAKE HOME POINTS Breast cancer is here with us. Patients are presenting with advanced breast diseaseEarly breast cancer has >90% survival rateLate breast cancer has < 30% survival rateIt is our responsibility to get these patients to present earlierBSECBEMammogram
70 REFERENCESAkhator A, Oside CP. Breast diseases in Warri. African J of Trop Med & Bio. Res 2010.Akhator A. Clinicopathological study of breast cancer in Eku. The Nigerian J of Clinical Practice 2008Adebamowo CA, Ajayi OO. Breast cancer in Nigeria. West Afr J Med 2000Guideline implementation for breast health care in low and medium income countries. The Breast health global initiative 2007Scottish intercollegiate guidelines network – management of breast cancer in women.
71 REFERENCESDisease Control priorities project – Controlling Cancers in developing countries. April 2007National Institute for Health and Clinical Excellence – Guidelines Early and Locally advanced breast. February 2009.National Institute for Health and Clinical Excellence – Guidelines Advanced breast cancerCancer screening in United States, 2007; A review of current Guidelines, practices, and prospects
73 POST TESTBreast cancer patients present commonly to breast clinic with early disease in WarriThe prognosis of breast cancer is related to the grade of the tumorHormone receptor assay is essential in the management of breast cancer.BSE is the most widely recommended method for screening breast cancerBreast conservative surgery is the best treatment for stage III disease.