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DR. A. AKHATOR FWACS, FICS SENIOR LECTURER DELSU CONSULTANT SURGEON DELSUTH.

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Presentation on theme: "DR. A. AKHATOR FWACS, FICS SENIOR LECTURER DELSU CONSULTANT SURGEON DELSUTH."— Presentation transcript:

1 DR. A. AKHATOR FWACS, FICS SENIOR LECTURER DELSU CONSULTANT SURGEON DELSUTH

2 1. Breast cancer is the most common cancer in women in Nigeria 2. Breast cancer is the most common cause of cancer related deaths 3. Breast cancer commonly present as painful breast lump 4. Prognosis of breast cancer is related to the size of the breast tumor 5. Trastuzumab (Herceptin R ) is treatment for ER/PR positive tumor

3  Realize the burden of breast cancer in our environment  The importance of early diagnosis in management of breast cancer  Evaluate breast cancer symptoms and recommend appropriate management

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5 BREAST

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7  Breast cancer – malignant neoplasm arising in the breast.  Most common cancer in women worldwide.  Incidence in Nigeria is 33/100,000  Incidence in males 1-9% of cases  Peak age 42 years  78% locally advanced disease  22% metastatic disease

8  APPROXIMATELY EVERY 3 MINUTES A WOMAN IS DIAGNOSED WITH BREAST CANCER  APPROXIMATELY EVERY 12 MINUTES A WOMAN DIES FROM BREAST CANCER  INCIDENCE INCREASING 5%/YEAR IN DEVELOPING COUNTRIES  A REVIEW 1991 – 33% ADVANCED DISEASE IN DEVELOPED COUNTRIES  2007 – 60-80% ADVANCED DISEASE IN DEVELOPING COUNTRIES

9  IN THE UK 2009  NEW CASES - 38,212 FEMALES, 250 MALES  SECOND COMMONEST CANCER DEATHS  IN US  211, 240 NEW CASES EXPECTED IN WOMEN  1,690 NEW CASES IN MEN  African-American women have a lower incidence but higher mortality  They also have higher risk for triple-negative tumours  INCIDENCE – 128.6/100,000 POPULATION  Life time risk of 1 in 8 women

10  Family History Lifestyle Personal History

11  Mother, 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  SHARED GENETIC MAKEUP  SHARED LIFESTYLE  SIMILAR ENVIRONMENTAL EXPOSURE  5-10% CAUSED BY INHERITED GENETICS

13  Previous history of breast cancer  Previous history of benign breast disease  Menarche <12 years  Hormonal contraceptives – current and recent users  Nullipara  First delivery after 30 years  Menopause at 55 years or older  Hormonal Replacement Therapy

14  Several studies found a lower incidence of breast cancer among women who exercise regularly  Higher proportion of breast cancer among obese women.  Smoking

15  ALCOHOL – one or more drinks a day increases risk  DIET – High in fruits and vegetables decreases risk  EXERCISE – Regular exercise decreases risk  WEIGHT – Maintaining healthy weight decreases risk

16  POLYCYCLIC AROMATIC HYDROCARBONS – Chemicals produced when coal, oil, gas, garbage are burnt – increases risk  SMOKING – Passive smoking increases risk; when smoking started as teenager  ELECTROMAGNETIC FIELD – NO RISK

17  SHAMPOO – NOT TRUE  WEARING BRA – NOT TRUE  PUTTING MONEY IN BRA – NOT TRUE  RADIATION FROM CELL PHONES – NOT TRUE  ANTIPERSPERANTS/DEODORANTS – NOT TRUE  BREASTFEEDING GRANDCHILDREN – NOT TRUE  WITCHES INFLICT – NOT TRUE

18  Heterogeneous disease at each stage  Early breast cancer (Tis-2/N0-1)  In situ disease  Invasive  Late breast cancer (T3,4/N2/M1)  Locally advanced  Metastatic disease

19  STAGE 0 – Tis, N0,M0  STAGE IA – T1, N0,M0  STAGE 1B – T0 or T1, N1mi, M0  STAGE IIA – T0 or T1, N1, M0; T2,N0,M0  STAGE IIB – T2, N1, M0; T3, N0, M0  STAGE IIIA – T0 to T2, N2, M0; T3, N1 orN2,M0  STAGE IIIB – T4,N0-N2,M0;  STAGE IIIC – any T, N3, M0  STAGE IV – any T, any N, M1

20 Total CancersPer Cent In Situ Carcinoma ** 15–30 Ductal carcinoma in situ, DCIS80 Lobular carcinoma in situ, LCIS20 Invasive Carcinoma70–85 No special type carcinoma ("ductal")79 Lobular carcinoma10 Tubular/cribriform carcinoma (Better prognosis than average) 6 Mucinous (colloid) carcinoma (Better prognosis than average) 2 Medullary carcinoma (Better prognosis than average)2 Papillary carcinoma1 Metaplastic carcinoma, (Squamous)

21  Early diagnosis leads to better prognosis  The size of the tumor and extend of spread determines the prognosis  Early stage  Better possibility for cure  Less morbidity  Less toxic treatment

22 1. Overall survival/Disease free interval 2. Quality of life a. Adverse effect/toxicity of treatment b. Body habitus c. Psychological

23  Age  Tumor size  Axillary LN status  Histological grade  Receptor status – ER, PR  HER2-neu(C-erb B2)

24  CURE RATES FOR BREAST CANCER  5 year cure rates of >90% obtainable for early tumours,  < 30% for late tumours

25  Stage 0 – 93%  Stage I – 88%  Stage IIA – 81%  Stage IIB – 74%  Stage IIIA – 67%  Stage IIIB – 41%  Stage IIIC – 49%  Stage IV – 15%

26  Scars of treatment/no breast  Younger survivors face  Emotional stresses  Trouble with social functioning  Chemotherapy induced early menopause  Sexual difficulties

27  ASYMPTOMATIC PATIENT  SCREENING  BSE  CBE  Mammography  MRI  SYMPTOMATIC PATIENT  Clinical evaluation  Diagnostic investigations

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29 1. It is simple and easy to perform. 2. It is convenient and requires little time. 3. It is private. 4. It involves no medical cost 5. It is safe and non-invasive. 6. It requires no specific equipment.

30  Pamphlets and leaflets.  Instructional videos.  Demonstrations and personal instructions.

31  Breast self examination – monthly  Understand the breast and look for changes 1. Development of a lump. 2. Swelling. 3. Skin irritation or dimpling. 4. Nipple pain or retraction. 5. Redness or scaliness of the nipple or breast skin. 6. Discharge - other than milk.  Standing and lying

32 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  BREAST EXAM BY DOCTOR (CBE) – EVERY 3 YRS BETWEEN 20-39YRS;  YEARLY AFTER 40YRS, before mammogram  POOR SENSITIVITY - 54%  HIGH SPECIFITY – 94%  CBE-detected tumours has 70% survival

34  XRAY OF THE BREAST (MAMMOGRAM) – YEARLY AFTER 40 YRS  Mammography-detected tumours has 90% survival  Mammography 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  TRIPLE ASSESSMENT 1. CLINICAL EVALUATION 2. IMAGING 3. HISTOCYTOLOGY

36  History  Progression of symptoms  Risk factors for breast cancer  Treatment to date  Physical examination  Local  systemic

37  Breast lumps – painless  Swelling of the breast  Nipple discharge – blood stained  Retraction of the nipple  Changes in the skin of the breast  Breast or nipple pain  Signs of spread

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49  Breast scan  Mammogram  Digital mammogram  Computer aided diagnosis (CAD)  MRI  OTHERS  Thermography  Scintimammography  Tomosynthesis (3D Mammography)

50  TYPES OF BIOPSY TECHNIQUE  FNAC  Core Needle  Vacuum assisted  Open biopsy  Incisional  excisional

51  SURGERY 1. Mastectomy + reconstruction 2. BCS  HORMONAL THERAPY  CHEMOTHERAPY  TARGETED THERAPY  RADIOTHERAPY

52  Large tumors  Centrally located tumors  Large tumors cf size of breast  Multicentric tumor – mammogram  Previous radiotherapy  Patient’s preference

53  Simple mastectomy + SLND  Skin-sparing mastectomy Nipple-sparing mastectomy  Modified Radical mastectomy  Breast reconstruction/breast form  Radiotherapy after mastectomy 1. Large tumors 5cm or larger 2. Deep seated tumors 3. 4 or more positive lymph nodes

54  BCS + RT = BCT  75% Px in developed countries  Tumor control rate of 80-90%  5 year survival rate – 70-88%  Local recurrence rate 2-10%  Without RT – 15-40%  TYPES OF BCS  Lumpectomy  WLE  QUART

55 1. Very small breast 2. Very large breast 3. Advanced/high grade disease 4. Lactating breast/pregnancy 5. Multicentric disease 6. Contralateral disease 7. Previous RT 8. Central tumors 9. Multiple tumors 10. Risk for 2 nd tumor

56  BCS is considered without radiotherapy if all of the following are present 1. Patients aged 70 years or older 2. Tumor is <2cm and has been completely excised 3. Tumor is hormone receptor positive and patient is placed on hormone therapy 4. No positive axillary lymph node

57  Combination, sequential therapy  Adjuvant/neoadjuvant setting  CMF  CAF; AC, TAC  Capacitabine  Common side effects  Hair loss  Nausea and vomiting  Fatigue  Stomatitis  Anorexia  Increased susceptibility to infections  Others – menstrual, heart, hand and foot syndrome, neuropathy, bladder

58  Tamoxifen; Raloxifene; Toremifene  Fulvestrant – eliminates receptor  Aromatase inhibitiors  Letrozole  Anastrozole  exemestane  Ovarian ablation  Oophorectomy  LHRH analogs – goserelin, leuprolide  Megastrol acetate  androgens

59  HER2/Neu monoclonal antibodies  Trastuzumab (Herceptin R )  Lapatinib (Tyrkeb R )  Angiogenesis inhibitors  Bevacizumab (Avastin R )

60  DCIS – BCS with 2mm margin  Pagets disease – BCS + removal of nipple- areolar complex  Invasive disease – BCS + SLN biopsy/ mastectomy  Start 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  Mastectomy  Primary/adjuvant systemic therapy  Biological Rx - trastuzamab  Uncontrolled local disease – wound management  Pain management  Lymphedema  Cancer related fatigue  Bone metastasis  Brain metastasis

62  142 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 symptoms  WHY ARE THEY COMING LATE?

63  Ignorance  Lack of facilities  Fear of diagnosis  Fear of the treatment  Alternative treatment options  Delay in referrals from peripheral centres  NO SCREENING PROGRAM

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68  NMA – active in promoting awareness of cancer especially breast cancer  NHIS – Include cancer screening as part of their healthcare provision  Provision of facilities – radiotherapy  Short trigger for referral of breast complaints

69  Breast cancer is here with us.  Patients are presenting with advanced breast disease  Early breast cancer has >90% survival rate  Late breast cancer has < 30% survival rate  It is our responsibility to get these patients to present earlier  BSE  CBE  Mammogram

70  Akhator A, Oside CP. Breast diseases in Warri. African J of Trop Med & Bio. Res  Akhator A. Clinicopathological study of breast cancer in Eku. The Nigerian J of Clinical Practice 2008  Adebamowo CA, Ajayi OO. Breast cancer in Nigeria. West Afr J Med 2000  Guideline implementation for breast health care in low and medium income countries. The Breast health global initiative 2007  Scottish intercollegiate guidelines network – management of breast cancer in women.

71  Disease Control priorities project – Controlling Cancers in developing countries. April 2007  National Institute for Health and Clinical Excellence – Guidelines Early and Locally advanced breast. February  National Institute for Health and Clinical Excellence – Guidelines Advanced breast cancer  Cancer screening in United States, 2007; A review of current Guidelines, practices, and prospects

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73 1. Breast cancer patients present commonly to breast clinic with early disease in Warri 2. The prognosis of breast cancer is related to the grade of the tumor 3. Hormone receptor assay is essential in the management of breast cancer. 4. BSE is the most widely recommended method for screening breast cancer 5. Breast conservative surgery is the best treatment for stage III disease.


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