The News on Breast Cancer

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The News on Breast Cancer

• January 2007
• Presented By Dail Jacob BScN, CONC

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• Somewhere in your life,
• you will meet someone
• who is touched by breast cancer.

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What is Cancer?

• Cancer is many diseases, the different types
  correlate with the origin of the cells involved.
• The human body is made of millions of cells,
  grouped together to form specific tissues and
  organs. The blueprint for cell structure
  function is DNA. Genes inside each cell order
  cells to grow, work, reproduce and die.
• Cancer cells are cells which have lost their
  original ordered life cycle and characteristics.
  Something environmental or internally commands
  the cells to grow and function differently.
• The abnormal growth of these cells eventually
  develop into a mass.
• Cancer cells can metastasize or spread to other
  parts of the body. They do this by direct
  invasion or by traveling through the lymph or
  blood circulation. Two classifications of cancer
  exist solid tumor and hematological cancer.

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What is Breast Cancer?

• Breast cancer is the most common occurring cancer
  in Canadian women.
• There are different types which can originate in
  different structures. The most common is ductal.
  others lobular, DCIS, invasive, Pagets,
  inflammatory.
• Most of the breast involves glandular tissue
  fat.
• The staging of the tumor once biopsied and the
  biochemical and morphological characteristics
  determine the stage of disease.

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Canadian Statistics

• In 2006, an estimated 22,200 women will be
  diagnosed with breast cancer and 5,300 will die
  of it.
• An estimated 160 men will be diagnosed and 45
  will die of it.
• On average, 429 Canadian women will be diagnosed
  each week.
• One in 9 women is expected to develop breast
  cancer during her lifetime. One in 27 will die of
  it.
• Since 1993, incidence rates for breast cancer
  have stabilized and death rates have declined
  steadily.
• The highest rates of breast cancer occur in the
  age bracket of age 50 69.

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What Causes Breast Cancer?

• There is no single cause of breast cancer but
  some factors appear to increase the risk of
  developing it
• Age
• Family history of breast cancer especially in a
  mother, sister or daughter diagnosed before
  menopause or if BRCA 1 or BRCA 2 genes are
  present. Heredity accounts for only 10 of all
  breast cancers
• Family history of uterine, colorectal or ovarian
  cancers
• Previous history of breast cancer, or biopsies
  which showed abnormal cells
• Dense breast tissue

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• Hormone exposure early menstruation, late
  menopause, no pregnancies or a late first
  pregnancy. It appears that the longer your body
  has been exposed to estrogen, the greater the
  risk. Use of Hormone replacement therapy HRT
  for more than 5 years has now also been linked to
  breast cancer. The choice to use HRT must be
  discussed with a doctor balancing the benefits
  with the risk.
• Obesity this is predominantly related to the
  fact that fat cells store estrogen.
• Alcohol intake alcohol intake of greater than 2
  drinks daily, has been linked with breast cancer.
• Environmental factors use of insecticides,
  pesticides, preservatives and hormones in food
  stocks are suspected of causing chromosomal
  changes in the host or altering metabolic and
  hormonal activities in the body.

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What Are Signs of Possible Breast Cancer

• A thickening or a lump felt in the breast or
  underarm
• A change in the size or shape of one breast that
  is different from the usual changes noted during
  your menstrual cycle
• A change in color or texture of the skin or
  underlying tissue of the breast
• Puckering or dimpling of the breast skin in one
  area as though something is pulling inside
• Or occasionally a discharge or bleeding from the
  nipple.
• The most common site of breast tumors in women
  is the upper outer quadrant of the breast. In men
  it is close to the nipple.
• If these signs are noted, a person should see a
  physician for assessment as soon as possible!
  Many patients out of fear do not seek help.

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Most Common Beliefs/Myths About Breast Cancer

• Only women with a family history get breast
  cancer? T/F
• By omitting smoking, drinking, alcohol,
  caffeine, and a high fat diet makes your chances
  of getting breast cancer almost zero? T/F
• Only women in their 50s get breast cancer? T/F
• If you have lumpy breasts, you are more likely to
  get breast cancer in the future? T/F
• An injury to the breast can cause breast cancer?
  T/F
• Stress has been associated with breast cancer?
  T/F

• 7. Breast cancer is associated with wearing an
  under wire bra and use of deodorant? T/F
• 8. Women who consume soy products, soya sauce
  and oysters have a reduced incidence of breast
  cancer? T/F
• 9. Microwave oven use is associated with
  increase cancer? T/F
• 10 Doing a self breast exam can prevent breast
  cancer? T/F
• 11 Doing a self breast exam in the shower is the
  best way to detect lumps? T/F
• 12 Small breasted women do not get breast cancer?
  T/F

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4 Steps to Diagnosis

• Self Breast Exam
• Clinical Exam
• Mammography
• Biopsy if indicated

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Staging of Disease

• Stage 1
• The tumor is no more than 2 centimeters
  (cm) across (T1)     
• The lymph nodes in the armpit are not
  affected     
• The cancer has not spread
• Stage 2 Divided into 2 groups
• Stage 2A means
• The tumor is less than 2 cm, the lymph nodes
  under the arm contain cancer but are not stuck to
  each other and the cancer has not spread or   
• The tumor is less than 5 cm, there are no cancer
  cells in the lymph nodes in the armpit and the
  cancer has not spread or   
• Although no tumor is seen in the breast, the
  lymph nodes under the arm contain cancer but are
  not stuck together, and there is no sign of
  spread to other parts of the body
• Stage 2B means
• The tumor is less than 5 cm and the lymph nodes
  under the arm contain cancer but are not stuck to
  each other, and the cancer has not spread or   
• The tumor is bigger than 5 cm across, there are
  no cancer cells in the lymph nodes in the armpit
  and the cancer has not spread

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• Stage 3 Stage 3 breast cancer is divided into
  3 groupsStage 3A means
• Although no tumor is seen in the breast, the
  lymph nodes under the arm contain cancer and are
  stuck together, but there is no sign of cancer
  spread or   
• The tumor is 5 cm or less, the lymph nodes in
  the armpit contain cancer and are stuck to each
  other, but the cancer has not spread
  elsewhere or   
• The tumor is more than 5 cm, the lymph nodes in
  the armpit contain cancer and may be stuck
  together, but there is no further spread
• Stage 3B means
• The tumor is fixed to the skin or chest wall, the
  lymph nodes may or may not contain cancer, but
  there is no further spread
• Stage 3C means
• The tumor can be any size and has spread to lymph
  nodes in the armpit and under the breast bone, or
  to nodes above or below the collarbone, but there
  is no further spread
• Stage 4
• The tumor can be any size     
• The lymph nodes may or may not contain cancer
  cells   
• The cancer has spread or metastasized to other
  parts of the body such as the lungs, liver or
  bones
• If you only have cancer spread to the lymph
  nodes in your armpit, you do not have stage 4
  breast cancer.  Stage 4 only applies to cancer
  spread to other body organs.
• The most common sites of distal metastasis
  include bone, lung, liver brain.

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Treatments

• Goals
• Cure
• Control
• Palliation
• A metastatic work up is often done before a
  surgical procedure is done. If the patient has
  distant metastasis, surgery may not be the first
  approach to management.

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Treatment of Breast Cancer

• Surgery
• Chemotherapy
• Radiotherapy
• Hormonal Therapy

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Surgery

• Complete or radical mastectomies are rarely done
  now. Some indications for still performing this
  procedure include multiple sites of tumor in the
  breast, inflammatory breast cancer or tumors
  which are large gt 5 cm or involving the skin,
  pregnancy where radiotherapy is contraindicated,
  previous radiotherapy, local recurrence of
  disease, lupus or scleroderma, severe cardiac or
  lung disease.
• The most common procedure is a partial
  mastectomy.
• Sentinel Node biopsy.
• Reconstruction
• Axillary Node Dissection, risk of lymphedema.

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Chemotherapy

• Indication Systemic control of disease.
• Recommend starting chemotherapy 4 6 weeks after
  surgery.
• Choice of which chemotherapy is guided by
  practice guidelines based on the type of breast
  cancer, the stage of disease, the characteristics
  of the tumor seen by the pathologist and goals of
  treatment.
• Can be given prior to surgery neoadjuvant. This
  is indicated for a large breast tumor or with
  inflammatory breast cancer.
• Many types of medications. Chemotherapy
  medications are usually given in combination to
  have a synergistic effect upon cancer cell
  destruction or prevention of cell duplication and
  growth.
• Gene therapy.
• Side effects of chemotherapy.

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• Radiotherapy
• Indication local control of disease.
• External beam or brachytherapy.
• Usually started 1 month after chemotherapy.
• Indications for boost therapy young patients
  with DCIS or patients identified to be at high
  risk for local recurrence.
• Side effects of radiotherapy.
• Hormone therapy

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Breast Cancer Recurrence

• In Canada, 14 women with breast cancer will
  eventually have a recurrence.
• For a subgroup of patients who are HER2 positive,
  the risk of recurrence was reduced with the
  upfront use of the drug Herceptin. This news in
  2004 changed the front line practice for this
  subgroup of patients. Approx. 25 of all breast
  cancer patients are HER2 positive. HER2 positive
  patients generally have a poorer prognosis
  therefore this outcome is great news.
• 3 types of recurrence take place
• Local
• Regional
• Distant
• Some of the prognostic indicators or indications
  that a patient may eventually reoccur include
  lymph node involvement ER/PR status Grade of
  the tumor clear margins tumor size oncogene
  expressions in the cells.

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Support Services for Cancer Patients

• Look Good/Feel Better
• Support Groups
• Educational Sessions
• Psychosocial support psychologist, pastoral
  care, social worker the nursing team
• Rehab Nutrition Exercise Programs
• Lymphedema Management
• Music Therapy, Art Therapy , Massage Therapy
• Resource Room with library, wigs prosthesis
  information
• Volunteers

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The Future

• Overall survivorship of patients with breast
  cancer has increased. We look at it as a chronic
  illness, though some patients will die of this
  disease.
• Many options of treatment and the research is
  focusing on more targeted therapies with fewer
  side effects.
• We have excellent medication and support services
  to help patients, and reduce the side effects of
  treatment
• A national Cancer Control Strategy has been
  established. Many provinces also have set up
  comprehensive programs to oversee the approach to
  diagnosis, management and outcomes.
• Canadians are becoming more health conscience and
  aware of environmental risks and concerns.
• Development of programs to achieve healing and
  wholeness after the cancer experience

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Testimonial of Personal Experience with Audrey
Phillips
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• Gastric Cancer

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Gastrointestinal Cancers

• Esophageal 1,200 1,400 new cases
• Gastric 2,800 3,200 new cases
• Colorectal 17,000 new cases. 3rd most common in
  incidence death.

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Stomach Gastric Cancer

• Stomach cancer starts in the cells of the
  stomach. The stomach is a muscular sac and is
  lined with glandular cells that produce acid and
  special proteins called enzymes which help to
  digest food.
• The most common type of gastric cancer is
  adenocarcinoma 85, which starts in the
  glandular cells in the lining of the stomach.
• There are 2 less common types
• Gastric lymphoma involves the lymph system
• Leiomyosarcoma involves the muscle
• Worldwide accounts for 3 of all cancers. Areas
  where there is a higher incidence include Japan,
  South America, Eastern Europe the Middle East.
• In Canada the areas of highest incidence include
  the Maritimes, Quebec and Manitoba.

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Etiology of Gastric Cancer

• No single cause
• Factors associated with increased risk include
• Age gt 50 age 50 59 highest incidence
• Gender 2X greater in men
• Diet higher incidence with salted or cured,
  pickled or BBQ foods. There is a higher incidence
  with low intake of fruits vegetables low in
  Vit. A or C.
• Smoking / ETOH
• Workplace exposure to asbestos, nickel, coal
  dust, gold mining, silica, chromium, oil mist or
  diesel emissions and rubber timber processing
  materials.
• Lower production of stomach acid than normal
• Helicobacter pylori bacteria
• H/O pernicious anemia Vit B12 deficiency
• H/O GERD gastro esophageal reflux disease
• Contaminated water source , lack of refrigeration
• Genetic small group Type A blood, nonpolyposis
  colon ca, Li Fraumeni syndrome.

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Signs Symptoms of Gastric Cancer

• Unfortunately, tumors in the stomach can grow for
  a long time before someone is aware of a problem.
  The symptom are often vague at first and resemble
  other gastric ailments such as ulcer disease.
• Indigestion / heartburn
• Bloating / fullness after meals
• Loss of appetite
• Nausea
• Abdominal discomfort, especially after eating
• Pain in upper back or upper chest
• Vomiting blood / Blood in stool
• Difficulty swallowing
• Change of bowel habit
• In the advance stages anemia, weight loss,
  Nausea vomiting, pain, jaundice malnutrition.

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Diagnosis of Gastric Cancer

• There is no routine screening for this disease.
• Report symptoms to family physician, clinical
  exam
• Blood work
• Gastroscopy biopsy.
• UGI Series
• Stool test for occult blood
• Metastatic work-up, as stage of disease will help
  determine the approach to treatment. CT scan,
  ultrasound, MRI, PET scan.

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Treatment of Gastric Cancer

• The best scenario for cure is if the patient is
  able to have surgical removal of the gastric
  tumor. Generally this involves a partial or total
  gastrectomy and resection of the nodes and
  adjacent tissues involved. In North America, only
  10 20 of patients are diagnosed in the early
  stages.
• Approximately 80 of patients have metastasis at
  the time of confirmed diagnosis.
• Other treatments include
• Chemotherapy
• Radiotherapy external beam or by brachytherapy
• Chemoradiation combined either before surgery or
  after
• Endoscopic laser surgery and insertion of stents
  to treat obstructions.
• Biologic therapies available in clinical trials
  involves a treatment that uses the patients
  immune system to fight cancer These substances
  made in the body or in a lab, are used to boost,
  direct or restore the bodys natural defenses.

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Patient Care Concerns

• Post operative complications
• Anastomotic leak
• Dumping syndrome
• Nutritional challenges
• Symptom control related to disease treatment
  option
• Pain control
• Nausea possible vomiting
• Mucositis or esophagitis
• Fatigue weakness
• Myelosuppression, particularly anemia
• Performance status ability to maintain
  functional status
• Recurrence of disease

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• Questions ?

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Resource Sites

• Canadian Cancer Society www.cancer.ca/ccs
• National Cancer Institute of Canada
  www.ncic.cancer.ca
• National Cancer Institute/ US National Institute
  of Health www.cancer.gov
• ASCO American Society of Clinical Oncology
  http//www.asco.org
• National Surgical Adjuvant Breast Bowel Project
  http//www.nsabp
• ASCO People Living With Cancer
  http//www.plwc.org
• Cancer Care Ontario http//www.cancercare.on.ca
• B.C. Cancer Agency www.bccancer.bc.ca