1. BREAST CANCER Oncology
John Dewar

2. Breast Cancer Commonest cancer in women
2nd commonest cause of death from cancer in women
Survival improving – 5 yr. survival improved from 56% 1970 to 79% in 1999 (year of diagnosis)
Increasing incidence – ageing population

3. Presentation Screening – age 50-64(70), small, impalpable
Symptomatic – lump in breast
8% with distant metastases
8% locally advanced/inoperable
84% operable

4. TREATMENT Surgery Radiotherapy Systemic therapy hormonal therapy
cytotoxic chemotherapy
immunotherapy

5. RADIOTHERAPY Postoperatively to breast/chest wall
nodal areas: axilla, supraclavicular fossa, internal mammary nodes
Primary radical for locally advanced
Palliatively to painful bony mets, skin deposits, brain mets etc.

6. POSTOPERATIVE RADIOTHERAPY
Reduces the risk of local recurrence by about two thirds:
60% to 20%
30% to 10%
3% to 1%

7. POSTOPERATIVE RADIOTHERAPY
All patients being treated conservatively (wide local excision/lumpectomy)
Mastectomy patients selectively – large tumour, extensive nodal involvement, involved margins etc.

8. Postoperative Radiotherapy – acute side effects
Skin erythema to moist desquamation
Tiredness
Dysphagia if irradiating supraclavicular fossa
No alopecia

9. Postoperative Radiotherapy – late effects
Local fibrosis and telangectasia
Lung fibrosis (rarely symptomatic)
Cardiac damage (ischaemic heart disease) – rarer now treatment better planned

10. Postoperative Radiotherapy – late effects
Survival
Overall 5% improvement in breast cancer survival (at 15 yrs.) for 20% improvement in local control (4% improvement in overall survival)
Localised local recurrence can act as nidus for distant metastases

11. SYSTEMIC THERAPY – adjuvant
Most operable, why not curable?
Occult distant metastases at presentation
Systemic therapy after surgery reduces the risk of recurrence and death – adjuvant therapy

12. SYSTEMIC THERAPY – adjuvant
Hormone therapy: ovarian ablation, tamoxifen, aromatase inhibitors (ER/Pg +ve patients only)
Cytotoxic chemotherapy: CMF, doxirubicin/epirubicin, taxanes
Trastuzumab [Herceptin]
All decrease odds of death by about 17%, absolute benefit of about 6% at 10 years.

13. SYSTEMIC THERAPY – adjuvant: side effects
Hormone therapy:
Infertility
Menopausal symptoms
Weight gain
Endometrial cancer
Deep venous thrombosis
Chemotherapy
Nausea & vomiting
Infertility
Alopecia
Neutropenia (sepsis)
Mouth ulcers
Lassitude

14. METASTATIC DISEASE Incurable but treatable
Optimise quality of life and survival
Median survival with mets: 2 years (20% at 5 yrs.)
Varies from acute aggressive disease to chronic disease (like diabetes, renal failure etc.)

15. METASTATIC DISEASE Assess extent of disease
Stage: local recurrence, lung, liver, bone
Hormone receptor status
HER2 receptor status

16. METASTATIC DISEASE Local problems
Palliative radiotherapy: bony mets, brain mets etc.
Drainage of pleural or peritoneal effusions
Pining of pathological fractures

17. METASTATIC DISEASE Systemic therapy
Hormone therapy if ER/Pg +ve
Chemotherapy
Bisphosphonates for bony mets
Trastuzumab if HER2 +ve

18. METASTATIC DISEASE Systemic therapy
ER +ve: Hormonal agents: ovarian ablation, aromatase inhibitors, tamoxifen, progestagens in sequence
unless liver mets or lymphangitis carcinomatosa when usually chemotherapy

19. METASTATIC DISEASE
Chemotherapy: CMF, anthracyclines, taxanes, capcitabine etc. etc.
Use in sequence so long as respond and patient fit

20. BREAST CANCER
Need multidisciplinary management: nurses, surgeons, radiologists, pathologists, oncologists, GP. etc. etc.
Different patients have different needs
Most will need considerable support
Major impact on the patients but also their families