1. Breast Cancer: What every medical student should know. Breast Cancer Awareness Month October 2009 For more information: www.amsa.org

2. Women agonize... over cancer; we take as a personal threat the lump in every friend's breast. Martha Weinman Lear, Heartsounds

3. Impact: With 1 million new cases in the world each year, breast cancer is the most common malignancy in women and comprises 18% of all women’s cancers. Breast cancer incidence in women in the United States is 1 in 8 (about 13%). Women have a 3% chance of breast cancer causing their death. For women in the U.S., breast cancer death rates are higher than those for any other cancer besides lung cancer. The American Cancer Society estimates that each year, about 2000 new cases of invasive breast cancer are diagnosed in men. It is estimated that about $8.1 billion is spent each year on breast cancer treatment in the U.S.

4. Epidemiology: Over 75% of women who are diagnosed with breast cancer are age 50 or older. The five-year relative survival rate is now 98 percent for women with breast cancer caught before it spreads beyond the breast (compared to 72 percent in 1982). Breast cancer incidence is greater in women of higher socio- economic background. The relationship of breast cancer risk with socio-economic factors is most likely related to life style differences like number of pregnancies and age at first childbirth. Death rates have been decreasing since 1990. These decreases are thought to be the result of treatment advances, earlier detection through screening, and increased awareness.

5. Incidence and Mortality of Female Breast Cancer Based on Race and Ethnicity in the U.S. Rate Per 100,000

6. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and life in general, not to inherited mutations. Current Age Probability of breast cancer in next 10 years 200.05% or 1 in 1,837 300.43% or 1 in 234 401.43% or 1 in 70 502.51% or 1 in 40 603.51% or 1 in 28 703.88% or 1 in 26 Lifetime risk: 12.28%; 1 in 8 women Probabilities of Developing Invasive Breast Cancer Based on Age

7. Hereditary Breast Cancer: While about 20-30% of women diagnosed with breast cancer have a family history of breast cancer, only about 5-10% of breast cancer cases are caused by inherited gene mutations. BRCA1 and BRCA2 mutations are the most common. Lifetime breast cancer risk Median age of breast cancer (years) General population 12% 61 BRCA1 65% 43 BRCA2 45% 41

8. Breast Cancer Kills Men,Too. Less than 1% of all new breast cancer cases occur in men. Men with a BRCA1 mutation have a 1% risk of developing breast cancer by age 70; BRCA2 mutations confer a 6% risk. Breast cancer prognosis, even in stage I cases, is worse in men than in women. Treatment for male breast cancer has usually been a mastectomy, which may be followed by radiation, hormone therapy (such as with tamoxifen), or chemotherapy. Risk factors for male breast cancer Testicular abnormalities: cryptorchidia, congential inguinal hernia, orchiectomy, orchitis, testicular trauma Hormonal alterations: Infertility, Klinefelter’s syndrome, obesity, cirrhosis (and heavy alcohol intake) Family history of breast cancer, mutations in BRCA1/2, CHEK2, PTEN Benign breast lesions: Nipple discharge, breast cysts, breast trauma Exposure to radiation or high temperatures Old age Jewish descent

9. Types of Breast Cancer DCIS: Ductal Carcinoma In Situ LCIS: Lobular Carcinoma In Situ IDC: Invasive Ductal Carcinoma ILC: Invasive Lobular Carcinoma Inflammatory Breast Cancer Male Breast Cancer Recurrent and Metastatic Cancer Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. Invasive ductal carcinoma (IDC) is the most common type of breast cancer, comprising about 80% of all breast cancers.

10. Signs to watch out for: a lump felt in the breast an inverted nipple nipple discharge (clear or bloody) nipple pain sores on the nipple and areola enlarged lymph nodes under the arm

11. Signs and Symptoms Rapid change in the appearance of one breast (days or weeks), with visible enlargement of one breast, discoloration with red, purple, pink or bruised appearance and warmth of the affected breast suggests Inflammatory Breast Cancer. In inflammatory breast cancer, cancer cells invade local lymphatic ducts, impairing drainage and causing edematous swelling of the breast. Peau d’orange: The skin of the breast is tethered by the suspensory ligament of Cooper, which, with the accumulation of fluid, can cause the breast to take on a dimpled appearance similar to an orange.

12. Inflammatory Breast Cancer Inflammatory breast cancer (IBC) accounts for between 1 percent and 6 percent of all breast cancer cases in the United States. The 5-year survival rate for patients with IBC is between 25-50 percent, significantly lower than the survival rate for patients with non-IBC breast cancer. IBC has a high risk of recurrence and is the most aggressive kind of breast cancer. IBC is more likely to have metastasized at the time of diagnosis than other breast cancer types. IBC affects women at an average age of 59 — about three to seven years younger than the average age at which other types of breast cancer are diagnosed. Men can develop the disease, but at an older age. Black women are slightly more likely than are white women to have IBC.

13. Risk Factors The most significant risk factors for breast cancer include gender (being female) and age (growing older). Factors with minimal or no risk include fertility treatment abortion, deodorant and folic acid. Short-term use of hormones for treatment of menopausal symptoms appears to confer little or no breast cancer risk.

14. Factors that Increase the Relative Risk (RR) for Breast Cancer in Women RR>4.0 Female Age (65+) Inherited genetic mutations associated with breast cancer such as BRCA1/BRCA2 Two or more first-degree relatives with breast cancer diagnosed at an early age Personal history of breast cancer High density breast tissue Biopsy-confirmed atypical hyperplasia 2.1<RR<4.0 One first-degree relative with breast cancer High-dose radiation to chest High bone density (post-menopausal) 1.1<RR<2.0 Factors affecting circulating hormones: Late age at first full-term pregnancy (>30 yrs) Early menarche(<12 yrs) Late menopause No full-term pregnancies No breastfeeding Recent oral contraceptive use Recent and long-term hormone replacement therapy Obesity Other factors: Personal history of endometrium, ovary or colon cancer Alcohol consumption Height (tall) High socioeconomic status Jewish heritage

15. Surveillance Mammography Sonogram MRI Clinical and self breast exam Risk Avoidance Diet and Exercise Chemoprevention Tamoxifen Raloxifene Prophylactic Surgery Bilateral Prophylactic Mastectomy Oophorectomy Breast Cancer Screening and Prevention

16. Mammograms: for low-income women and the uninsured. Mammograms are usually covered by health insurance for women in the recommended age bracket. While some insurance plans have no out-of-pocket expenses required, others charge a $10-$35 co-pay. Uninsured patients pay the full-price cost of a mammogram, which ranges from $80 to $120. Some state and local health programs and employers provide mammograms free or at low cost. Health departments, hospitals, women’s centers, or other community groups may also have information on how to access low-cost or free mammograms. The Centers for Disease Control and Prevention (CDC) coordinates the National Breast and Cervical Cancer Early Detection Program to provide screening services, including clinical breast exams and mammograms, to low-income, uninsured women throughout the United States. Visit the CDC website to find contact information for local programs Information about low-cost or free mammography screening programs is also available through NCI’s Cancer Information Service (CIS) at 1–800–4–CANCER (1–800–422–6237).

17. Conventional Treatments Surgery Chemotherapy Hormonal therapy Radiation Just over the horizon: breast cancer vaccine trials are under way with vaccines like NeuVax, which stimulates anti-Her2 immune response, and Stimuvax, moving into phase III trials.

18. Triple Negative Breast Cancer: Triple negative breast cancer (TNBC) is clinically characterized by the lack of expression of estrogen, progesterone and HER2 hormone receptors. Comprises about 10-20% of breast cancers: more than one out of every 10. Does not respond to current hormonal therapy (such as tamoxifen or aromatase inhibitors) or therapies that target HER2 receptors, such as Herceptin (trastuzumab). Women diagonosed with TNBC generally face a poorer prognosis. Treatments that target other processes may be helpful in treating triple negative breast cancer when combined with chemotherapy: Avastin: interferes with VEGF (vascular endothelial growth factor), inhibiting the growth of new blood vessels at the tumor site. Erbitux: interferes with EGFR (epidermal growth factor receptor), which is often overexpressed in triple negative cancer. PARP inhibitors: inhibit poly (ADP-ribose) polymerase, an enzyme used by cancer cells to repair DNA damage. One PARP inhibitor, dubbed BSI-201, has been shown to improve survival in triple negative breast cancer patients by 60% when added to standard chemotherapy drugs.

19. The Breast Cancer Experience Physical changes to the breasts and side effects such as hair loss, fatigue and lymphedema Changes in sexuality and desire, premature menopause, infertility Mental and emotional changes such as “chemobrain,” depression and fear of recurrence Positive lifestyle changes such as increased exercise, healthier eating, stress reduction Changes in relationships with family and friends Financial hardships, occupational changes

20. Complementary medicine can improve quality of life for breast cancer patients: Acupuncture Meditation Aromatherapy Guided Imagery Hypnosis Journaling Chiropractic Therapy Massage Spirituality & Prayer Reiki Support Groups Tai Chi Shiatsu Yoga Music Therapy Progressive Muscle Relaxation

21. In the year 2008, there were about 2.5 million women in the U.S. who considered themselves breast cancer survivors.

22. Advocacy