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BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS

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Presentation on theme: "BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS"— Presentation transcript:

1 BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS
DR. A. AKHATOR FWACS, FICS SENIOR LECTURER DELSU CONSULTANT 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 deaths Breast cancer commonly present as painful breast lump Prognosis of breast cancer is related to the size of the breast tumor Trastuzumab (HerceptinR) is treatment for ER/PR positive tumor

3 LEARNING OBJECTIVES 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

4 OCTOBER IS BREAST CANCER AWARENESS MONTH

5 BREAST

6

7 INTRODUCTION 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 THE FACTS ABOUT BREAST CANCER
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 MORE FACTS IN THE UK 2009 IN US INCIDENCE – 128.6/100,000 POPULATION
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 Factors that increase risk
Lifestyle Family History Personal History

11 Family History 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 FAMILY HISTORY SHARED GENETIC MAKEUP SHARED LIFESTYLE
SIMILAR ENVIRONMENTAL EXPOSURE 5-10% CAUSED BY INHERITED GENETICS

13 PERSONAL HISTORY 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 Lifestyle Several studies found a lower incidence of breast cancer among women who exercise regularly Higher proportion of breast cancer among obese women. Smoking

15 OTHER LIFESTYLE FACTORS
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 ENVIRONMENTAL RISK 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 BREAST CANCER MYTHS 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 CLASSIFICATION 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 GROUPING 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 In Situ Carcinoma * 15–30 Invasive Carcinoma 70–85 Total Cancers
Per Cent In Situ Carcinoma * 15–30 Ductal carcinoma in situ, DCIS 80 Lobular carcinoma in situ, LCIS 20 Invasive Carcinoma 70–85 No special type carcinoma ("ductal") 79 Lobular carcinoma 10 Tubular/cribriform carcinoma (Better prognosis than average) 6 Mucinous (colloid) carcinoma (Better prognosis than average) 2 Medullary carcinoma (Better prognosis than average) Papillary carcinoma 1 Metaplastic carcinoma, (Squamous)

21 EARLY DIAGNOSIS ….. 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 PROGNOSIS Overall survival/Disease free interval Quality of life
Adverse effect/toxicity of treatment Body habitus Psychological

23 PROGNOSTIC FACTORS Age Tumor size Axillary LN status
Histological grade Receptor status – ER, PR HER2-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 stresses Trouble with social functioning Chemotherapy induced early menopause Sexual difficulties

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

28 Breast Self Exam Be Safe, Be Sure

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 cost It 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 – monthly Understand the breast and look for changes Development 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 mammogram POOR 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% 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 EARLY DIAGNOSIS TRIPLE ASSESSMENT CLINICAL EVALUATION IMAGING
HISTOCYTOLOGY

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

37 FEATURES OF BREAST CANCER
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

38 LUMP IN THE BREAST

39

40 LUMP IN THE AXILLA

41

42 RETRACTED NIPPLE

43 RETRACTED NIPPLE

44 INFLAMMATORY BREAST CANCER

45 BLOODY NIPPLE DISCHARGE

46 BREAST ULCER

47 BREAST ULCER

48 Breast cancer in a man Risk factors for male breast cancer: Family Hx, BRCA2 gene, Klinefelters syndrome, Hepatic schistosomiasis, Radiation exposure

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

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

51 TREATMENT SURGERY Mastectomy + reconstruction BCS HORMONAL THERAPY
CHEMOTHERAPY TARGETED THERAPY RADIOTHERAPY

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

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

54 Breast conservation surgery
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 CONTRAINDICATION TO BCT
Very small breast Very large breast Advanced/high grade disease Lactating breast/pregnancy Multicentric disease Contralateral disease Previous RT Central tumors Multiple tumors Risk for 2nd tumor

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

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

59 TARGETED THERAPY HER2/Neu monoclonal antibodies
Trastuzumab (HerceptinR) Lapatinib (TyrkebR) Angiogenesis inhibitors Bevacizumab (AvastinR)

60 EARLY BREAST CANCER 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 ADVANCED BREAST CANCER
Mastectomy Primary/adjuvant systemic therapy Biological Rx - trastuzamab Uncontrolled local disease – wound management Pain management Lymphedema Cancer related fatigue Bone metastasis Brain metastasis

62 BREAST CANCER IN WARRI 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 WHY ARE THEY COMING LATE
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 WAY FORWARD 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 TAKE HOME POINTS 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 REFERENCES Akhator 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 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 REFERENCES 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 2009. 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

72 THANK YOU AND GOD BLESS

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


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