1. Breast Cancer Anne Kelly RN,MS,NP-C AOCNP October 25,2017

2. Disclosures None

3. Outline Epidemiology Risk Factors Screening Diagnosis Treatment
Genetic testing
Research

4. Epidemiology
2017 :estimated new cases of invasive breast cancer in women
Additional 2470 cases of breast cancer in Men
Most common cancer among women
1/8 women (12%) will develop invasive breast cancer in there life time
40,610 death from breast cancer in 2017
This is 16% of patient diagnoses (population risk from breast cancer related death among women is about 3%)
2nd leading cause of cancer death in women ( Lung Cancer is 1 st)
Death rates have been declining since 1989
More than 2.8 million breast cancer survivors

5. Non-Modifiable Risk Factors
Gender
Age
Personal History
Early Menopause
Race /Ethnicity
Dense Breast Tissue
LCIS
Family History
Genetic History
Late Menopause
Exposure to Chest Radiation before age 30

6. Modifiable Risk Factors
Hormone replacement
Late first full-term pregnancy
Oral contraceptives
Obesity after menopause
Nulliparity
Alcohol consumption

7. Screening for Breast Cancer
Mammogram
MRI
Self Breast exam
Clinical breast exam

8. MAMOGRAM Stanard vs.3 D (tomosynthesis) Screening vs Diagnostic
What do we see on Mammogram

9. NCCN Screening guidelines Average Risk
Clinical encounter every 1-3 yrs.
Breast awareness
Age 40
Clinical encounter yearly
Annual Mammogram
Clinical encounter+ ongoing risk assessment , risk reduction counseling, and a clinical breast exam

10. NCCN Screening Guidleines High risk
Personal Hx breast cancer
>20% life time risk
Chest radiation before age 30
Genetic mutation ( family Hx suggestive of mutation)

11. NCCN Screening Guidleines High risk cont.
Clinical encounter every 6-12 months starting at age risk is identified but not earlier than 30 (Chest wall radiation beginning 8-10 yrs after tx )
Annual mammogram ( not earlier than 30)
Consider annual MRI ( not before age 25)
Breast awareness
Consider risk reduction
Healthy living
Surgery
Pregnancy
Tamoxifen

12. Synptoms of Breast Cancer
Abnormal mammogram
New Lump or Mass
Skin or nipple Changes
-dimpling, irritation, redness, scaliness, thickening
Breast or nipple pain
Nipple retraction
Nipple bleeding/discharge
Lymphadenopathy

13. Inflammatory Breast Cancer
Automatically considered Stage III (skin involvement)
35% are metastatic at diagnosis
Usually no single lump or tumor
1-6% of all breast cancers
Presents with erythema of breast and peau d’orange
Hallmark: dermal lymphatic involvement
Poor prognosis
Just a quick note about IBC in case you see it in your practice b/c time is of the essence in IBC
The propensity for metastatic disease is so high that you have to start with chemotherapy very quickly
Approach to treatment: Pre-op chemo, mastectomy, PMRT, endocrine therapy if ER+
American Cancer Society

14. Diagnosis Diagnostic Mammogram Ultra Sound Biopsy
Referral to surgeon and or/Medical oncologist
MRI??

16. American Cancer Society
DCIS is a non-invasive or pre-invasive lesion
The cells within the ducts have changed, but have not spread or invaded through the walls of the ducts into surrounding breast tissue
It has no ability to spread or metastasize outside of the breast if it’s treated properly (which is how it differs from LCIS)
Lot of recent controversy lately regarding whether or not we over-treat DCIS
American Cancer Society

17. Types of Breast Cancer Cell type Receptors Non invasive Invasive
Lobular
Ductal
Invasive
Inflammatory
Estrogen
Progesterone
Her 2 nu
Hormone positive ER + Her 2 nu +-
ER/ PR- Her 2 nu +
Triple negative

18. Treatment Decision Making Multiple Factors
Tumor Size
Nodes involved
Tumor Grade
Subtype
Patient Age
Patient other medical problems
Oncotype

19. AJCC Breast Cancer Staging Stage Description 5-Year Survival Rate I
≤ 2 cm, node negative
95-100%
IIA
2-5 cm, node negative
< 2 cm, node positive
92%
IIB
> 5 cm, node negative 2-5 cm, node positive
81%
IIIA
> 5 cm, node positive
< 5 cm, node positive with matted lymph nodes
67%
IIIB
Tumor penetrated to the skin of breast or chest wall or spread to internal mammary nodes
54% IV
Distant metastases
20%
American Joint Committee on Cancer (AJCC) was established in 1959 to formulate and publish systems of classification of cancer, including staging and end results reporting, which will be acceptable to, and used by, the medical profession for selecting the most effective treatment, determining prognosis, and continuing evaluation of cancer control measures.
Comprised of multiple member organizations (ACS, ASCO, CDC, etc.)

20. Local treatment Surgery Radiation Lumpectomy Mastectomy
After Lumpectomy
After mastectomy
Hypo fractionated

21. Systematic Treatment Chemotherapy
Before surgery (neoadj treatment)
Post surgery (adjuvant)
Hormonal /Endocrine therapy for Estrogen + disease
Tamoxifen
Aromatase Inhibitors
Endocrine therapy is usually give 5-10 yrs. reduces risk of recurrence by about 50% where as Chemotherapy reduces risk by about 1/3

22. Advanced Disease Incurable, but treatable; goal is palliative
Common sites Liver,Lung, Bone, Brain Skin
Treatment approach : sequential single-agent therpaies
ER+: endocrine therpay first.unless high tunor burdon/ Very symptomatic
Several different chemo agents
4 differnet HER 2 Nu targeted agents available
Novel agents/ Clinical trials

23. Genetic testing Family Hx Breast cancer diagnose at young age
BRCA 1 and 2 genes
Gene Arrays

24. Survivorship How do we follow people after diagnosis of breast cancer
Nutrition
Exercise
Sexual Health
Potential long tern complication form treatment
Fertility
Neuropathy
Cardiac Dysfunction
Lymphedema
Secondary Cancers

25. Research
1987 – Her-2 amplification correlated with poor overall survival
2013 – Tamoxifen x 10 years
1975 – Adjuvant chemo shown to prolong life
1894 – Halsted’s Mastectomy
2004 – Aromatase Inhibitors introduced ??
2008 – hypo-fractionated radiation = conventional radiation
1940s – OS in pre-menopausal women
1977 – Tamoxifen FDA approved
1993 – SLNB shown to reliably predict axillary status
2015 – Ibrance FDA approved
1977 – Lumpectomy + XRT = Mastectomy

26. References American Cancer Society
NCCN Guidelines
American Society of Clinical Oncology (ASCO)
Oncology Nursing Society

27. Thank You Any Questions ? Anne Kelly akelly@partners.org