Breast Cancer Protocol Western Visayas Medical Center Hospital Cancer Committee

Breast Cancer Statistics Most common site-specific cancer in women worlwide 2nd most common cause of cancer death in women 5th most common cause of death in women 8-12% lifetime risk of developing breast cancer

Breast Cancer (WVMC) Most common cancer in female being treated in the wards (20 surgical cases admitted for 2008) Majority of patients in Clinical Stage IIb, III and stage IV Majority of patients in Pathologic stage III Treatment is mostly surgical Poor follow-up

Breast Cancer Symptoms Breast mass – 33% Others Nipple changes (retractions, discharges) Ulceration/erythema of the skin of breasts Breast enlargement/asymmetry Axillary mass

Breast Cancer Early Detection

Breast Cancer Screening Breast self-exam (BSE) every month starting the age of 20. (1-2 weeks after 1st day of menstruation. Clinical breast exam (CBE) starting the age of 20 and every 3-5 years thereafter Clinical breast exam at the age of 40 then yearly thereafter. Mammography starting at the age of 40 then yearly thereafter. Mammography at age 35 for high risk patients.

Risk Factors in Breast CA Hormonal risk factors Early menarche Nulliparity Late menopause Obesity Hormonal pills/HRT Nonhormonal risk factors Old age First degree relatives with breast cancer Radiation therapy Alcohol consumption High fat diet

Survival Rate of Breast CA 5-year survival rate IIa - 85% IIb - 70% IIIa - 52% IIIb - 48% IV - 18%

Imaging Techniques Mammography* - 30% reduction in mortality rate from breast cancer Screening mammography - women with no symptoms Diagnostic mammography - women with symptoms Breast Ultrasound – adjunct to mammography Ductography* - for women with bloody nipple discharges MRI* - for high risk patients with dense breast during mammography

Treatment of Breast CA Surgery Chemotherapy* Radiotherapy Breast conserving surgery (lumpectomy, quadrantectomy) Mastectomy Modified radical mastectomy Chemotherapy* Adjuvant chemotherapy Neoadjuvant chemotherapy Radiotherapy Hormonal therapy* Antiestrogen (Tamoxifen) – hormone receptor (+) pre and postmenopausal 25% reduction in breast cancer recurrence 7% reduction in breast cancer mortality Aromatase inhibitors (anastrozole/letrozole)- hormone receptor (+) postmenopausal Biologic therapy*- antiHER2/neu antibody therapy (herceptin/trasruzumab) Ablative endocrine surgery

Breast cancer staging Stage I Stage II Primary tumor is 2 cms or less with no lymphatic spread Stage II IIa – no tumor but 1-3 positive axillary nodes; primary tumor is 2 cms or less with (+) 1-3 axillary lymph nodes, (+) SLNB; tumor 2-5 cms with no axillary spread IIb – primary tumor is 2-5 cms with spread to 1-3 axillary lymph node; tumor >5 cms with no axillary spread

Breast cancer staging Stage III Stage IV IIIa-no tumor but with 4-9 axillary lymph node; <5cms but with 4-9 axillary lymph node; >5 cms but does not grow into chest wall or skin IIIb-tumor has grown into chest wall and skin with no axillary lymph node or with 1-3 lymph node; or 4-9 lymph node IIIc-tumor of any size with spread to 10 or more axillary lymph node or supraclavicular lymph node Stage IV Spread of breast cancer to distant areas of the body

Breast Cancer Treatment Pathways

Non- Palpable Breast Mass History/PE Doubtful clinical breast exam, high risk, >40 years old Normal Clinical Breast Exam, <low risk, <40 yo Breast Ultrasound/Mammography Mammogram/Stereotactic needle not available (+) lesions (-) lesions Image Guided Biopsy (Ultrasound/ mammography) Observe Malignant Benign

>40 any size, high risk, <40 but mass 2cm or more Hx and PE Palpable Breast Mass >40 any size, high risk, <40 but mass 2cm or more <40, <2 cms in size, low risk Biopsy (FNAB/Excision or incision biopsy) Benign Malignant Non-invasive DCIS LCIS Invasive Infiltrating Ductal CA, others Observe Complete excision if incision biopsy was done Clinical Staging Early Stage (I-IIIA) Late Stage (IIIB-IV)

Mastectomy/Modified Radical Mastectomy Early Breast Cancer (DCIS, Stage I,II,IIIA) Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2 Mastectomy/Modified Radical Mastectomy Breast Conserving Surgery (with axillary dissection) Axillary Nodes High nuclear grade,high histologic grade, HER2 + may proceed with chemotherapy (-) (+) Chemotherapy Radiotherapy Observe Hormone Receptor Oophorectomy for premenopausal (+) (-) Tamoxifen HER2/neu (+) tumors may be started with Herceptin Postmenopausal Aromatase inhibitors

Advance Stage Breast Cancer (Stage IIIb-IV) Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2, hepatic UTZ, bone scan Chemotherapy Modified Radical Mastectomy/Mastectomy Breast Conserving Surgery Adjuvant Chemotherapy Radiotherapy Hormone Receptor (+) Tamoxifen Postmenopausal Aromatase inhibitors HER2/neu (+) tumors may be started with Herceptin

Recurrent Breast Cancer (loc0regional and distant metastasis) Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2, hepatic UTZ, bone scan Biopsy (for local recurrence) Chemotherapy Radiotherapy Hospice Care

Sentinel lymph node biopsy Use for women with T1 and T2 N0 breast cancer (+) sentinel node biopsy Axillary dissection and node clearance necesary (-)sentinel node biopsy Axillary dissection not necessary

Biomarkers Predict prognosis and response to therapy Predict more accurately the disease free and overall survival rate than clinicopathologic staging These tumors tend to grow faster and recur more often EGFr and HER2/neu overexpression signifies high nuclear grade and high proliferation aneuploidy Trastuzumab(Herceptin) 52% decrease in breast cancer recurrence

BRCA mutations BRCA-1 and BRCA-2 Tumor suppressor gene BRCA-1 BRCA-2 90% lifetime risk of developing breast cancer BRCA-2 85% lifetime risk of developing breast cancer Cancer prevention for BRCA mutation carriers Prophylactic mastectomy Prophylactic mastectomy and HRT Intensive suveillance Chemoprevention

BCS vs Mastectomy Factors why women choose mastectomy over BCS Fear of recurrence in remaining breast Fear of dying from breast cancer High cost of radiation with BCS Distance from radiation facility Older women favor mastectomy

Chemotherapy regimen Node negative women Node positive women CMF FAC FAC or CEF AC +/- T A – CMF EC

Thank you and good morning.