1. Modern Imaging in Breast Cancer Dr Linda Hacking Consultant Radiologist

2. October is Breast Cancer Awareness Month Breast cancer is commonest cancer in UK (excluding non-melanoma skin cancer) 46,000 new cases per year 300 men, remainder women 80% over 50 years of age 1 in 9 women will get it in their lifetime

3. Bad news/Good news Incidence has increased by 50% in last 25years 12,000 women and 70 men died from breast cancer in 2008 1,300 deaths in women under 50 More than half deaths are in women over 70

4. Bad news/Good news Since 1980s breast cancer death rates have fallen by one third Breast cancer is no longer the commonest cause of cancer death in women More than 8 out of 10 women survive beyond 5 years (5 out of 10 in 1970s) Now twice as likely to survive 10 years as 40 years ago. 2 out of 3 women survive beyond 20 years Breast cancer death rates falling faster in UK than rest of Europe

5. Reasons for improvements in outcomes Screening Improved treatments (Tamoxifen etc) Improved cancer services including imaging

7. Why are these improvements happening Breast screening?? (also increased diagnosis rate) Improved treatments (tamoxifen etc.) Overall improvements in care (including imaging)

8. Breast Screening NHS Breast Screening Programme (NHSBSP) Began 1988-90 Not Blackpool Victoria. Nearest centre Lancaster (vans, WGD) Invited for Mammograms from age 50-69 Extended from 47-73 years from 2012 (target) Past upper age limit, option to arrange mammogram.

9. Breast Screening Will cause increase in incidence of cancer Early cancers and pre-cancer (DCIS) are found that would never have led to a problem

10. For Breast Screening One woman will be over-treated for every two lives saved 1000 lives a year saved Impact on population vs individual woman’s life.

11. Against breast screening 10% of cancers are over-diagnosis and therefore over –treatment It is impossible to estimate lives saved because of all other factors Impact on population vs impact on individual woman’s life

12. Today we are talking about diagnosis

13. The Symptomatic Breast Clinic Lump or thickening Change in size or shape Redness or rash in skin or nipple Indrawing of nipple Skin puckering or dimpling Lump in armpit

14. Referral to Breast Clinic May simply need to see senior clinician- no further –advice, no further investigations. Triple assessment/Double assessment See Senior Clinician (1) Imaging (2) Biopsy or needle test (FNA) (3)

15. Modern Imaging and Biopsy Tests to be done at first clinic appointment for most patients Most patients will have a benign diagnosis Less than 1 in 10 patients attending our clinic will have a malignant diagnosis 9 out of 10 will be benign In new clinic, results for patients seen Monday, Tuesday available for Friday Wednesday, within a week

16. Modern Imaging and Biopsy Quick accurate diagnosis for the majority of patients who will have a benign diagnosis As much information as possible about what we are dealing with in the minority if patients who have a malignant diagnosis Treatment can then be tailored to the individual patient

17. Mammography Symptomatic patients Women >35 years of age Uses x-radiation Invented in 1960s, modern type of machine 1969 Still not in universal use 1986 (when I started in radiology) First unit Blackpool 1990 (Fylde Coast incl.NHS) Blackpool Victoria Mammography unit 1999. October 2010 Full Field Digital mammography

26. Mammography Problems X-radiation Dense breasts Young women Men Implants No imaging 100% accurate

27. Field Digital Mammography Better on all counts Dense breast Younger women Less radiation

33. Ultrasound First imaging <35, and men To clarify lumps and cysts on mammogram To do image guided biopsy To look at axilla (armpit)

34. Ultrasound

35. Cyst

36. Fibroadenoma

37. Ultrasound guided biopsy

38. Needle guided into abnormality under direct vision Can be needle test (FNA) Or Core biopsy Uses local anaesthetic Takes 5-10 minutes “a bit like getting ears pierced” Complications- bruising, pain

39. Ultrasound guided biopsy Quick very accurate results A patient specific individual plan if surgery required Tumour grade if malignant Hormone receptor status (Tamoxifen, herceptin) Size and extent of mass(es) Lymphnodes Test done Tuesday, results Friday

40. Core Biopsy Needle

41. Ultrasound guided biopsy

42. Mammographic stereotactic biopsy Mass seen on mammogram, not on ultrasound Micro-calcification “chalky bits”- can be benign, can be malignant or pre-malignant (DCIS) No lump felt Standard core biopsy Vacuum assisted core biopsy Special devices

43. Mammographic stereotactic biopsy Previously may have needed general anaesthetic surgery to remove abnormality Now outpatient procedure under local anaesthetic Most turn out to be benign

44. Vacuum assisted biopsy

46. Vacora vs 14G biopsy

47. Sample can be x-rayed

51. Breast MR (magnetic resonance)

52. Breast MR Also major investment in breast coils and software for new MR scanner Increased comfort Ease of interpretation (software)

54. Breast MR Recently in press In UK not used in every case Lobular carcinoma Multifocal carcinoma Problem solving when imaging/clinical/pathology do not match Doubts about mastectomy/ local excision Question of recurrence Implants

61. Breast MRI Adds to planning of surgery

62. So far We have been talking about diagnosis Imaging also helps during surgery

63. Localisation of mass not felt Marker with ultrasound Wire with stereotactic mammography Mass can be x-rayed while patient still anaesthetised

64. Excised specimen

65. Also during surgery-Sentinel Lymph Node Biopsy (SLNB)

66. SNLB Small amount radioactivity injected into breast On morning before afternoon surgery Or afternoon before morning surgery Also blue dye in theatre Goes to first lymph node Surgeon uses probe in theatre No drain, much reduced complication rate compared with Node Clearance Seroma, lymphoedema, pain, numbness Overnight stay vs several day stay

67. SLNB A small percentage will require further surgery once node examined in lab Nodes examined with ultrasound and FNA prior to surgery Not suitable for everyone

69. Surgical probe

70. The Future Tomosynthesis On table sentinel node diagnosis Answers about breast screening

71. http://www.youtube.com/watch?v=P5n3Avqq o2c

72. To Summarise Blackpool Victoria has opened a brand new breast clinic We have the latest technology available for the best possible care for our patients The new clinic pathway for rapid access and diagnosis will benefit all of our patients Most patients will have a benign diagnosis delivered quickly

73. For the few patients who unfortunately have a malignant diagnosis They will be treated quickly, with all of the latest technologies available We should be able to upgrade for the future

74. The outlook is good

75. Thanks to the team!