Case 3 Jane McNicholas Consultant Oncoplastic Breast Surgeon East Lancashire Hospitals

Case 3 74 year old woman presents with lump in left breast she noticed 2 weeks ago In past, was on HRT for 7 years No FH of breast cancer Otherwise fit and well

Case 3 On examination - 2cm mass in left breast, hard, discrete, feels malignant. No axillary nodes to feel - P5 Mammogram - 2cm mass in left breast - M5 Ultrasound - 22mm lesion in breast - U5 Ultrasound of axilla - normal FNA - malignant cells - M5 Core Biopsy - Invasive Ductal Cancer, Grade 2 - B5b

Case 3 What do you offer the patient?

Case 3 WLE + SLNB Mastectomy + SLNB Axillary node clearance only if SLNB shows metastatic disease Post-op radiotherapy? Post-op chemotherapy? Endocrine therapy?

Case 3 Patient chooses WLE and SLNB Post op histology - 19mm Grade 2 Invasive Ductal Cancer, fully excised. No evidence of lymphovascular invasion. 0/4 lymph nodes ER - 8/8, PR - 7/8, Her2 - -ve What is her NPI?

Nottingham Prognostic Index Score 1 2 3 Grade Lymph nodes 1-3 4+ NPI = Grade + Lymph Nodes + (Size (cm) x0.2)

Nottingham Prognostic Index

Case 3 NPI = 2 + 1 + (1.9 x 0.2) = 3.38 Puts patient into a good prognosis group Post-operative MDT recommended radiotherapy and endocrine therapy (Aromatase inhibitor)

Reasons for Mastectomy Patient choice Large tumour in relation to breast size Previous breast conserving surgery with radiotherapy Multi-focal disease Unable to have radiotherapy (unable to lie flat, unable to raise arm, pacemaker with left sided tumour Patients with collagen vascular diseases Central breast tumour - No longer a valid reason

Post-op Radiotherapy Always given after WLE - local recurrence rate unacceptably high if not given (i.e 25% in 10 years) Given after mastectomy in patients thought to be at higher risk of local recurrence (i.e. close to chest wall, large tumour, vascular invasion, etc

Post-op Chemotherapy Given to patients at high risk of disease recurrence/progression Usually node positive, large tumour, adverse histological features, oestrogen receptor negative, herceptin positive Traditionally given up to 70, but this is changing - over 70 given in many more cases if fit enough

Endocrine Therapy Given to patients who are Oestrogen Receptor positive First used was Tamoxifen. Side effects include hot flushes (50%), increased thrombo-embolic risk, increased risk of endometrial cancer Newer agents more widely used now - Anastrozole (Arimidex), Letrozole (Femara) and Exemestane (Aromasin). Side effects are hot flushes (30%) and reduced bone mineral density

HRT and Breast Cancer The Million Women Study is the largest study looking at HRT usage and breast cancer risk It found that taking HRT for 5 years increased the risk of breast cancer This increased risk was for Oestrogen only and Combined Preparations but Combined preparations had a greater risk