1. Breast Cancer Protocol
Western Visayas Medical Center
Hospital Cancer Committee

2. 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

3. 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

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

5. Breast Cancer
Early Detection

6. 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.

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. Breast Cancer
Treatment Pathways

14. 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

15. >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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. Thank you and good morning.