Breast Cancer DRYDEN TANNER & ALEX DOIRON

Overview  Introduction  History  What is it?  Pathophysiology  Facts & Stats  Signs & Symptoms  Diagnosis  Risk Factors  Treatment  Future Research

Introduction  Breast cancer refers to a malignant tumor that has developed from cells in the breast.  Two possible locations to develop within the breast  Breast Cancer can develop in BOTH women and men however, predominantly in women

Introduction  Most common cancer diagnosis in Canadian women over 20  1 in 9 Canadian women is expected to develop breast cancer  1 in 29 Canadian women will die from breast cancer

History

 Known since ancient time  Long been a stigma towards the disease  Recent phenomenon with women actively bringing out the disease into the open  Pink Ribbon introduced as a symbol for breast cancer in 1990’s

What Is Breast Cancer?

What is it?  Breast cancer is a malignant tumour that starts in the lobes or ducts of the breast.  Our Friends in the UK can help explain

What is it? Anatomy

What is it? Distinguishing Between Sites of Origin. Ductal Carcinoma (invasive or non-invasive):  Breast cancer starts in cells that line the ducts; tubes that carry milk from the glands to the nipple. Lobular Carcinoma (invasive or non-invasive):  Cancer can also start in the cells of the lobules; the groups of glands that make milk.

Pathophysiology

Pathophysiology: Inherited Genes, Mutations or Defects  5-10% breast cancer cases are considered directly related mutations in BRCA1 or BRCA2.  Classified as Tumor suppressor genes.  Carrying mutations in BRCA1/2 genes have a 50-80% lifetime risk of breast cancer.

Pathophysiology: Types of Breast Cancer Breast Cancer can also be triggered by problems with:  Hormone Reception  HER2 Protein Synthesis These problems distinguish the four types of breast cancer.

Pathophysiology: Endocrine Reception  Cancers that are estrogen or progesterone receptor positive (ER/PR- positive) have a significant number of that hormone receptor  The cancer responds and grows to that hormone respectively.

Pathophysiology: Protein Synthesis  Human Epidermal Growth Factor Receptor 2 (HER2)  Cells make too much of a protein known as HER2.  These breast cancers tend to be much more aggressive and fast-growing.

Pathophysiology: Types of Breast Cancer  Endocrine receptor (estrogen or progesterone receptor) positive  HER2 positive  Triple negative, not positive to receptors for estrogen, progesterone, or HER2  Triple positive, positive for estrogen receptors, progesterone receptors and HER2

Facts & Stats

New breast cancer cases diagnose in Canadian women2013 (#) Annually23, 800 Weekly (average)456 Daily (average)65

Facts & Stats CanadaBCABSKMBONQCNBNS #23,8003,1002, ,3006, %100%13%9&3% 39%25%2%3% Estimated new breast cancer cases by province in Canada in 2013 PENL %1%

Facts & Stats New breast cancer cases diagnosed in Canada, by age group 2013 (#)2013 (%) 80+2,90012% 70 – 794,30018% 60 – 696,40027% 50 – 595,90025% 40 – 493,30014% Under 401,0554%

Facts & Stats All %85%90%89%90%88%80% Five-year relative survival rates for breast cancer by age group (men and women) The current five-year survival rate (88%) has been improving since Canada’s worst breast cancer mortality rate (79%) in 1986.

Facts & Stats  Breast Cancer mortality rates in Canada were at their highest in 1986  42% decrease since then  Result of increased and better screening technologies, early detection through mammography screening and improved treatments

Facts & Stats  157,000 Canadian women wo had breast cancer diagnosis in the last ten years are living  Women with breast cancer are living for longer periods of time following their cancer diagnosis compared to other types of cancer.

Facts & Stats: US Males’ Statistic  In 2015, predicted to be:  About 2,350 new cases of invasive breast cancer will be diagnosed  About 40 men will die from breast cancer  Breast cancer is about 100 times less common among men than among women  The lifetime risk for men to get breast cancer is about 1 in 1,000

Signs & Symptoms

Signs & Symptoms: Video 

Signs & Symptoms: For Women  a lump in the breast – the most common first sign  a lump in the armpit (axilla)  changes in breast shape or size  skin changes  nipple changes

Signs & Symptoms: For Men  Breast swelling and tenderness  All others are identical as the ones for women

Diagnosis

Diagnostic tests Take place after:  Symptoms of breast cancer are present.  A doctor suspects breast cancer after discussing health and completing a physical examination.

Diagnosis: Steps for Diagnosing Breast Cancer Diagnosis follow’s a multi-step process  Step 1: Patients are identified by screening or symptoms.  Step 2: Imaging is done by either ultrasound or mammography.  Step 3: Biopsy or fine needle aspiration is done if a lump is detected by imaging or if clinically it appears suspicious.  Step 4: Pathological diagnosis distinguishes benign and malignant breast disease.

Diagnosis: Step 1  Patients are identified by screening or symptoms. Screening takes place as:  Mammogram  Clinical or self breast examination

Diagnosis: Step 2  Imaging is done by either ultrasound or mammography. Mammogram:  Accurate in detecting calcifications as well as small non-palpable lesion in postmenopausal women with non-dense breast tissue. Ultrasound:  Better at detecting fluid-filled lesions (cysts) and small tumours in dense breast tissue

Diagnosis: Step 3  Biopsy or fine needle aspiration is done if a lump is detected by imaging or if clinically it appears suspicious.

Diagnosis: Step 4  Pathological diagnosis distinguishes benign and malignant breast disease.  Staging is done using the TNM system, but molecular markers correlate better with prognosis.

Diagnosis: Staging Reflects the size of the primary tumour and the extent of local and distant spread. TNM System: T = tumour size and local invasion.  T0 = carcinoma in situ (no local invasion), followed by T1-T4 N = regional lymph node involvement.  N0 = no nodes, following by N1-N3 in increasing number of nodes M = distant metastases.  M0 = no metastasis, follow by M1 for metastasis

Diagnosis: Stages  Stage 0—non-invasive carcinomas (LCIS or DCIS). Cancer cells have not invaded the surrounding breast tissue.  Stage I—the tumor is no more than 2 cm in size and cancer cells have not spread beyond the breast.  Stage II—either the tumor has spread to the lymph nodes under the arms but the tumor is less than 2 cm  in size, or the tumor has not spread to the lymph nodes under the arms but is greater than 5 cm in size, or the tumor is between 2 and 5 cm and may or may not have spread to the nodes.  Stage III—the tumor is greater than 5 cm in size and has spread to the lymph nodes under the arms.  Stage IV—the cancer has spread to other parts of the body (metastatic cancer).

Risk Factors

Risk Factors: Known Factors  Personal history of breast cancer  Family history of breast and other cancers  BRCA gene mutations  Dense Breasts  Ashkenazi Jewish ancestry  Rare genetic Conditions  Reproductive History  Exposure to Ionizing radiation

Risk Factors: Known Factors Cont’d  Being Obese  High Socio-economic Status  Tall Adult Height  Hormone Replacement Therapy  Oral Contraceptives  Atypical Hyperplasia  Alcohol

Risk Factors: Possible Factors  Physical Inactivity  Adult Weight Gain  Smoking and Second Hand Smoke  Birth Weight  Night Shift Work  Some Benign Breast Conditions

Risk Factors: Myths  Antiperspirants  Deodorants  Abortion  Breast Implants  Bras  There is significant evidence showing that there is no association between these factors and breast cancer.

Risk Factors: Reducing Risk via Lifestyle Changes  Limit alcohol intake  Control weight, particularly after menopause  Breast feed  Exercise  Discontinue Hormone Therapy  Avoid exposure to carcinogens

Risk Factors: For Men  Some men with breast cancer do not have any identifiable risks  Most men diagnosed with breast cancer are over the age of 60  Family History  Certain Genetic Mutations  Radiation Exposure

Risk Factors: Possible Factors for Men  Being Obese  Alcohol  Estrogen Treatment

Treatment

Treatment: Surgery In most cases, choice of what type of breast surgery the patient would prefer:  Breast-conserving Surgery  Mastectomy  Axillary lymph node dissection  Adjuvant therapy

Treatment: Radiation Therapy External beam radiation therapy:  Always given after breast-conserving surgery, sometimes given after a mastectomy.  Systemic radiation therapy may be offered with breast cancer that has spread to large areas of the bone (bone metastases).

Treatment: Endocrine Therapy Hormonal therapy is offered for hormone receptor–positive breast cancer (ER+, PR+ or both) that is:  Early stage with a low risk of recurrence  Locally advanced, advanced or recurrent

Treatment: Chemotherapy Chemotherapy is offered for breast cancer that is:  Early stage with a high risk of recurrence  Locally advanced, advanced or recurrent Drugs used depend on the stage of breast cancer. May include a combination or a single drug

Treatment: Study - Harder (2015)  Looked at women with early-stage breast cancer.  Randomised to Standard care plus or minus a yoga DVD for 10-weeks.  Patient-reported outcomes were collected at baseline, 10 weeks and 6 months.

Treatment: Study - Harder (2015) cont’d Results:  69% improvement from baseline arm morbidity subscale,  Numbness in the affected arm was greater in the standard care group lacking yoga  74% of women would definitely recommend following the yoga DVD after surgery.  Practising post-operative exercises does improve arm and shoulder morbidity following breast cancer surgery.

Future Research

Future Research: Awareness Ads and commercials that are:  Sentimental  Funny  Sexualized This to increase awareness To show the value of early detection via self-examination.

Future Research: Study – Burgess and Murray (2014)  Surveyed 255 college students  Investigated the relationship of awareness of breast cancer campaign and their knowledge of the risk factors, symptoms and detection of breast cancer.  The two campaigns observed were the Susan G. Komen campaign and the “I <3 BOOBIES” campaign  Used a multiple-choice questionnaire to assess their knowledge about breast self-exam, mammography and breast health

Future Research: Study – Burgess and Murray (2014)  Results:  Knowledge of breast self-exam and mammography did differ depending on which campaign students were aware of.  The scores of the survey were greater in the students who were aware of the Susan G. Komen campaign compared to the “I <3 BOOBIES” campaign.  The more campaigns students could identify, the more symptoms the could identify and were more knowledgeable about mammography and breast self- exam.  However, campaign identification was not related to risk factor identification.

Future Research: Awareness Ad 

References   ada.aspx ada.aspx        Harder, Helena, et al. "Post-operative exercises after breast cancer surgery: Results of a RCT evaluating standard care versus standard care plus additional yoga exercise." European Journal of Integrative Medicine (2015).  Burgess, Melinda C. R., and Ashley B. Murray. “Sexualization of Awareness: Catchy, but does it Actually Increase Knowledge of Breast Cancer?” College Student Journal 48.2 (2014): Web