Guidelines in management of breast cancer (UK experience)

1
Guidelines in management of breast cancer (UK
experience)

• HAMDY ELMARAKBY MD FRCS

2
Breast Pain (cyclical or not)

• No mass, mild pain
• - lt35 years reassure and discharge.
• - gt 35 years mammography
• No mass, moderate to severe pain
• - lt 35 ultrasound
• - gt 35 mammography
• Good support bra night and day, reduce caffeine
  intake, discontinue smoking, low fat diet, change
  the type of contraceptive pills and
• Evening primrose capsules
• - Gamolenic acid 240-300mg
• - 3-4 months at least
• - Danazol 100mg daily, assess after one month
  
• and continue for 6 months if response.

3
Cystic disease ( fibrocystic or not)

• Palpable cysts, 7 of western women.
• U/S, Mammography according to the age group.
• Aspirate (free hand or ultrasound)
• - No blood, no residual lump, not
  re-accumulating discharge
• - Rapidly recurrent, or blood re-image, FNAC
  ?excision?
• Multidisciplinary meeting (MDM).

4
Breast Cancer Diagnosis

• Monday am clinic (new patient) one stop (triple
  assessment).
• Wednesday pm multidisciplinary meeting (MDM).
• - Surgeons, Oncologist, Radiologist,
  Pathologist, breast care nurses, secretaries
• Thursday am New follow ups
• Thursday pm all other follow ups

5
Diagnosis

• Breast lump, asymmetric thickening, nodularity,
  nipple discharge.
• Triple assessment clinical examination,
  radiological (ultrasound, mammography), Biopsy(
  wide bore needle, FNAC).
• P value, U value, R value 1-5(normal, benign,
  uncertain, suspicious, malignant).
• Any P3,U3, R3 should be biopsied.
• One stop clinic patient will be given another
  appointment for the results if P3,U3,R3.
• FNAC is only used with too small or inaccessible
  lesions and with nipple discharge.
• All discordant results should be discussed in the
  MDM.

6
Ultrasound/Mammography

• Ultrasound breast abnormalities in ages lt35
  years, however,
• It should not used in pain, and not as screening
  tool.
• Mammography
• - Breast abnormalities in ages gt35 years.
• - National screening programme gt50
• years.
• - Early Screening (age lt 50years,family).
• - Nipple discharge.
• - Follow up in diagnosed breast cancer.

7
MRI

• Ill defined tumours/ breast conservative surgery.
• Multifocal disease?
• Assessment of the integrity of breast
  prosthesis?.
• Decision should be made at the MDM as mammography
  has taken over.

8
Excision biopsy

• Diagnostic uncertainty on core biopsy or FNAC.
• Lump gt30mm in all age groups.
• Discuss and consider excision of all lumps in gt
  35 years even if P2,R2.
• MDM discretion

9
Breast Discharge

• Single duct
• FNAC performed by surgeons.
• - Benign (c2) or negative for blood
• see 3 monthly for a year.
• - Uncertain (C3) or ve for blood
• consider surgery ( micro-
• dechoctomy lt50 years, macro-
• dechoctomygt50 years).
• MDM

10
Breast Discharge, continued

• Multiduct
• - Bilateral benign (c2) or negative for
  blood,
• reassure and discharge.
• - Unilateral same criteria /follow up 3
  monthly
• for a year.
• - Uncertain (C3) or ve for blood, or
• troublesome consider mammmo dechoctomy
• after discussion in MDM.
• Consider hyper prolactinaemia or drug induced
• galactorhea if profuse bilateral and
• embarrassing.

11
Other investigation tools

• All patients should have FBC, LFT, CXR and
  bilateral mammogram.
• No routine bone scan or liver US for operable
  breast cancer unless abnormal routine tests or if
  symptoms suggestive of metastasis.

12
Surgery

• D.C.I.S.
• Operable breast cancer.
• Locally advanced disease.

13
Non surgical treatment

• Adjuvant chemotherapy.
• Adjuvant hormone treatment.
• Adjuvant Radiotherapy.
• Neo-adjuvant Chemotherapy.

14
Male breast cancer

• lt1 of breast cancer and lt 1 of all male
  cancers.
• Guidelines are essentially the same as female
  breast cancer.
• Clinical outcome when matched for age, stage and
  treatment protocol are similar to females (
  Perkins and Middleton BMJ 2003).

15
Surgery for early breast cancer

• Non invasive breast cancer (DCIS)
• - No absolute consensus.
• - Lesions lt 4cm WLE with 1cm safety
• margin. No axillary surgery.
• - Lesions gt 4cm or multifocal consider
  mastectomy.
• - Axillary node sampling if extensive
  multifocality (1-5 lymph node involvement) (
  Dixon 1998)
• - DXT beneficial
• - Hormonal treatment less certain ( Lancet IBIS
  trial 2003).
• Lobular carcinoma in situ (LCIS) a marker lesion
  for increased risk of invasive cancer/close
  surveillance.

16
WLE
17
WLE Augmentation Mammoplasty
18
Invasive Breast Cancer (Early)

• Breast Conservative Tumour (BCT) solitary lt3cm,
  or selected cases with gt 3cm in large breast
  (MDM).
• Contraindications
• - multifocal,
• - recurrent disease after BCT,
• - patient choice,
• - tumour gt 3cm,
• - centrally placed tumors, or
• - if DXT is contraindicated,
• - pregnancy,
• - agelt 35 years( MDM).

19
Breast Conservative Surgery (BCS)

• A cylinder of breast tissue from skin to deep
  fascia is removed.
• No skin is removed unless superficial tumor.
• Macroscopic radial margins should be at least
  10-20mm and microscopic margins at least 5mm.
• Radiopaque clips 1( anterior surface),2(medial
  surface), 3(inferior surface).
• Silk suture on tissues closest to nipple.

20
Breast conservative surgery
21
Whats next

• Specimen x ray for all cases with a detectable
  mammographic abnormality.
• If close margin immediate re-excision at same
  operation.
• 4 axillary node sampling if axillary clearance is
  not indicated.
• ER and PR status in all patients.
• Mark the cavity with 4 clips on the pectoral
  fascia for DXT( superior, inferior, medial and
  lateral).

22
Treatment of axilla

• Incidence 1(DCIS),5-28(T1), 48(T2), 68(T3),
  88(T4).
• Axillary sampling (4 node)
• - if clinically N0
• Axillary clearance if N1 or FNAC and if
  mastectomy is indicated for recurrent disease.
• Not indicated if previously treated with
  radiotherapy.

23
Locally advanced Breast Cancer

• large cancer(T3-4), skin or muscle or chest wall
  infiltration, matted L.N.
• Full screen for metastasis( bone scan, liver US,
  possible CT chest).
• MDM select cases for adjuvant chemotherapy and
  hormonal ttt (Cancer981150-60, 2003).

24
Locally advanced Breast Cancer

• Hormonal slowly growing, ER PR, unfit patients
  for chemotherapy.
• Chemotherapy inflammatory carcinoma, ER, PR ve,
  young patient lt35.
• Value down staging,
• Definitive surgery will entirely depend on the
  tumor response.

25
Chemotherapy

• Adjuvant( in addition)/Neo-adjuvant (in
  advance/instead) of surgery.
• Details pathology tumour size, grade, nodal,
  receptor status, margins of excision and the
  presence or absence of vascular or lymph-vascular
  invasion.
• Indications (risk factors) ve nodes, grade 2-3,
  sizegt2cm,vascular invasion and receptor ve
  tumors.
• Anthracycline based e.g. 6 cycles of
  Epirubicin,5FU, Cyclophosphamide. Other
  combinations Epirubicin, Cyclophosphamide and
  Taxane.

26
Chemotherapy continued

• HER2 receptor status is becoming increasingly
  important particularly in relapse patients who
  are candidates for Trastuzumab (Herceptin).
• The benefits of chemotherapy in postmenopausal
  patients is increasingly appreciated making the
  traditional classification of patients into pre
  and post menopausal less crucial.
• Chemotherapy is not routinely offered to
  patientsgt65years.

27
Hormonal therapy

• All patients with estrogen/ progesterone
• receptors positive.
• Tamoxifen 20mg/day for 5 years.
• Exceptions previous tamoxifen therapy or
  history of thrombo-embolism.
• Should not simultaneously prescribed with DXT
  for fear of increased risk of pulmonary fibrosis.
  (Radiother Oncol 2002,Br J Cancer 2004).
• Should not simultaneously prescribed with
  chemotherapy as it reduce its effect and
  significantly increase the incidence of
  thromboembolism.
• ATTOM trial 5 more years of tamoxifen after
  finishing a 5 year treatment. Provided that the
  patients are disease free and had a complete
  resection of tumors.

28
Arimidex (Anastrozole)

• A non steroidal aromatase inhibitor.
• ATTAC trial suggests it is stronger with better
  prognosis and lesser side effects than tamoxifen.
• Nevertheless more arthralgia and fractures
  complication (Lancet 2005).
• Receptor ve postmenopausal.

29
Adjuvant Radiotherapy

• Post BCS DXT is given to the breast and the
  lower axilla in the tangential glancing fields.
• DXT should be considered for all patients with
  completely excised DCIS who had undergone BCS.
• Only those with lesions lt10mm should be discussed
  at the MDM.
• 4500-5000 cGY in 20-25 fractions daily. Options
  to give boost in younger patients.
• DXT to supraclav. L.N Should be considered with
  4 or more pathologically involved axillary L.Ns,
  apical nodes involvement and with extra nodal
  spread of tumor.

30
Post-mastectomy Radiotherapy

• Chest wall
• - 4 or more pathologically involved axillary
• nodes,
• - primary tumor gt5cm(large breast)
• - and tumor 3-5cm( small breast),
• - narrow deep margin lt0.5cm,
• - evidence of lymph vascular invasion.
• Irradiation to the axilla is only for those who
  have not had axillary clearance.

31
Follow up

• Access to breast care nurse/unscheduled
  outpatient review and for post 5 years follow
  ups.
• Patients are seen for 5years in the breasts
  cancer follow up clinic starting from 2 weeks
  postoperative where the results are conducted.
• Alternating appointment every 3months between the
  oncologist and the surgeon for 2 years, then very
  6 months for 3years.
• Clinical examination to the breast and the lymph
  nodes.

32
Follow UP

• Mammography is requested annually for 5 years.
• After 5 years if lt 50years, arrange biennial
  mammography until 50years.
• ifgt50years then discharge to NHSBSP for 3yearly
  screening.
• IFgt70years self referral for 3yearly screening.
• All patients diagnosed with distant metastasis
  should stop mammography surveillance.
• Other investigations are only requested if
  symptoms develop e.g. back pain, lump, rash etc

33
Breast reconstruction

• Patients should be aware prior to surgery for the
  possibility of breast reconstruction.
• Primary? Delayed?
• All patients should be offered the opportunity to
  meet another patient who underwent BR.

34
Breast Reconstruction
35
Breast reconstruction
36
Quality standards

• All patients with suspected breast cancer should
  be seen by specialist within 2 weeks of GP
  referral.
• More than 90 of GPs must receive feed back from
  the breast unit within one week of patients
  appointment.
• One stop clinic Clinical, imaging, biopsy should
  be performed at the initial visit.

37
Quality standards

• gt90 of patients should be diagnosed
  preoperatively.
• lt10 of patients should attend the hospital for
  more than one visit for diagnostic purposes.
• gt90 of diagnosed patients should be admitted for
  surgery within 2 weeks and 100 within 4 weeks.
• BCS, BCN, MDM are compulsory.

38
Outcome of breast cancer

• 60 of patients will develop some form of
  recurrence, 2/3(40) will develop within 5 years.
• 50 will eventually present with distant
  metastasis and die from the disease.
• Nottingham prognostic index (NPI) Grade(1-3) N
  Stage (N 0-2)(1-3) (0.2xsize of tumor in cm)

39
Outcome of breast cancer

• No (negative axilla), N1 (low axilla, N2 (high
  axilla).
• Good (scorelt3.4)(80 10 year survival ),moderate
  (score 3.4-5.4)(40 10 year survival) , poor
  (score gt5.4) (1510 year survival).
• Example 2cm,G2,N1 0.422 4.4 moderate

40
Family history

• Genetic predisposition in 5-10.
• However 15 of patients give family history.
• Pedigree analysis questionnaire and qualitative
  risk assessment will be made.
• Refer to regional genetic cancer clinic.

41
Family History

• Risk factors a close female relative had breast
  cancer lt40, or had bilateral breast cancer or
• 2 close female had breast cancer lt 60 or one had
  breast and the other had ovarian cancer or both
  had ovarian cancer.
• A male close relative had breast cancer at any
  age.
• A close relative denotes a first and second
  degree.
• Refer to regional cancer genetic clinic.
• Moderate and high risk female will have an annual
  clinical assessment and mammography starting from
  the age of 35- 40 years.
• At 50 years they are discharged back to the
  NHSBSP

42
Thank you
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64
(No Transcript)
65
(No Transcript)