1. Miss B.N. Shah Consultant Surgeon Ealing Hospital
Breast Cancer Update
Miss B.N. Shah
Consultant Surgeon
Ealing Hospital

2. Current Incidence of breast cancer
Common disease
8% risk of development up to 74y
Varies between countries
Rare <20y
25 per 100,000 from 30-34y
200 per 100,000 from 45-50y
463 per 100,000 from 70-79y

3. Incidence by race

4. Bad news Commonest cause of death in women aged 40-50y
Second commonest cause of death from cancer in women overall
Only 20-50% at most, related to attributable risk

5. Good news
Breast cancer mortality has fallen both in the UK and USA for the past decade
56% 5 year relative survival ( )
70% 5 year relative survival ( )

6. Mortality

7. anatomy

8. Lobule of the breast

9. Epidemiology

10. Influence of oral contraception (1)
Weakly associated with breast cancer risk
Single study evaluated effect on women with F.H
Cohort –showed R.R 3.3 among sisters and daughters of probands
Risk most evident before and during 1975

11. Influence of oral contraception (2)
Population based studies don’t show this effect
Estimated excess number of cancers between starting use and 10 years after stopping 0.5-5%
No hard evidence of increased risk of having breast cancer diagnosed 10y or more after stopping

12. Influence of HRT (1)
Data more extensive , variable, many confounding issues
No long term RCT’s
Collaborative group on Hormonal Factors in Breast Cancer
Meta-analysis of 90% of world data
54,000 women, 33% had used HRT for 5 y or more

13. Influence of HRT (2) Two main consistent findings
The length of time on HRT was related to extra breast cancers in users
This increased risk disappears within 5y of stopping
Women who use HRT for a short time around the menopause have a very low excess risk

14. Influence of HRT…..nitty, gritty
Cumulative incidence for women aged 50-70y is 45 per 1,000 in ‘never users’
2 per 1,000 extra cancers after 5yrs on HRT
6 per 1,000 extra cancers after 10yrs
12 per 1,000 extra cancers after 15yrs

15. HRT…what to do? RCTs in UK, Italy, Scandinavia and Canada
Each patient treated on their own merit
Apply the principle of ‘ treatment tailored strategies’

16. Genes and hereditary factors (1)
Susceptibility genes responsible for only 5-10% of breast cancers
great strides in characterising genes responsible
Almost nothing known about various gene interactions +/- environmental factors

17. Genes and hereditary factors (2)
1990 BRCA1 (17q) responsible for 90% of cases with autosomal dominant transmission of breast cancer and ovarian cancer
45% in breast cancer alone
BRCA2 (13q)

18. Genes and hereditary factors (3)
Hereditary breast cancer
Onset <45y
excess bilateral cancer
Multiple primary cancer
80% BRCA1, 20% BRCA2
Ashkenazi 1:100 risk of breast /ovarian/both
Screening useful

19. Genes and hereditary factors
Familial breast cancer
Positive FH
1 or more 1st or 2nd degree relatives that do not fit the HBCa category
Risk ratios increase with the number of affected relatives
Quantitative risk assessment helpful
Genetic testing not yet feasible

20. Genes and hereditary factors (3)
Multiple cancer syndromes
Li-Fraumeni syndrome (p53 mutation)
Cowden ‘s disease (mutation of PTEN gene)
Ataxia Telangectasia (11q)

21. The future Rapid progress – clinical and molecular genetics
find ways to cost DNA testing
?legislaton to prohibit discrimination
‘genetic labelling’- employers,insurance companies etc.

22. GP practice
The Department of Health point out that a GP with a list of 2000 patients is likely to see only one woman a year who has breast cancer. But they will see a lot more women who have non-cancerous breast conditions such as
Cysts - sacs of fluid in the breast tissue and most common in the year age group
Fibroadenomas – a collection of fibrous glandular tissue and most common in year age group
Diffuse nodularity – ‘lumpy’ breasts, which are common in all age groups up to the age of 50
Breast pain – this is not a common symptom of breast cancer
Although 9 out of 10 breast lumps are not cancer, the Department of Health recommends that any woman over 30 who has a lump in the breast that does not go away should be examined by her GP. 

23. Early referral A distinct lump in women under 30
‘Lumpy’ breasts that do not go away after a period has finished
A sore infected area on the breast (abscess)
Recurrent cysts
Breast pain that does not go away with reassurance, painkillers prescribed by your GP and wearing a well supporting bra
Any type of nipple discharge in women over 50
Any woman under 50 who has a blood stained discharge or a discharge from both nipples that is enough to stain clothing

24. Guidelines for Urgent Referral
The symptoms that need urgent referral in 2 weeks for possible cancer of the breast are
An area skin on the breast that is inflamed and sore (ulcerated)
Small lumps that appear just under the skin nodules - these are often shiny and red
Dimpling or distortion of the skin, called peau d'orange
A rash on a nipple or surrounding area called nipple eczema
Nipples that have turned in (inverted) within the past 3 months

25. Triple assessment
Clinical
Imaging
Pathology

26. Imaging Ultrasound (U) Mammagram (M) 1- normal 2 - benign
3 - probably benign
4 - probably malignant
5 - malignant

27. Cytology C1 - inadequate sample C2 - definitely benign
C3 - probably benign
C4 - probably malignant
C5 - malignant

28. Core Biopsy B1 - normal B2 - benign B3 - probably benign
B4 - probably malignant
B5 - malignant

29. Management of a lump

30. Management of a lump

31. Management of a lump

32. Management of a lump

33. Management of a lump

34. Lymphatic drainage

35. Management of the axilla
Clearance
Levels,1, 2, 3
Sample
4 nodes
Sentinel node
50:50 divide

36. Sentinel Node axillary dissection
Guided localisation
minimally invasive alternative to traditional
axillary dissection
Blue dye
Radioisotope
<5% false negative
The future

37. Screening (U.K.)
Two view
Double reading
50-65years
3 yearly

38. UK Trial of early detection of breast cancer
1999
27% decreased breast cancer mortality
45 – 60years
Supports Edinburgh trial (21%)

39. Anatomy