RECENT DEVELOPMENTS IN TREATMENT OF BREAST CANCER

1
RECENT DEVELOPMENTS IN TREATMENT OF BREAST CANCER

• BY
• DR.DILIP MURARKA
• MS, MCF (USA)
• Consulting Surgeon / Surgical Oncologist

2
(No Transcript)
3
Parts of the Breast
4
Breast (Sagittal View)
5
BREAST CANCER
Statistics

• Mortality all over the world 400,000
  annually
• Mortality in U.S.A. 43,000
  annually
• Incidence in U.S.A. 1,80,000 in
  women
• 1,000 in men
• Age adjusted incidence U.S.A. White U.S.A.
  Black Mumbai
• 1983 study 104.2/100,000
  87/100,000 20.5/100,000
• Bombay cancer registry 1987 Parsee Hindu
  Muslim Christian
• 
  47.2 22.8 25.7 26.2-

6
BREAST CANCER SCENARIO
The incidence of breast cancer is rising in every
country of the world especially in developing
countries such as India.

• Incidence
• Incidence is rising in India
• 1 in 28 women (urban areas)
• 1 in 80 women (rural areas)
• It is more prevalent in the higher
  socio-economic groups.
• Roughly 100000 new cases annually
• approx 3 increase per year
• Tata Hosp - Registered new cases annually
  - 2000
• Early breast cancer 55
• Locally advanced 35

7
SIGNS

• No Classic Signs
• Certain specific signs
• -Peau dorange
• -Inflammatory
• Ca Breast
• -Pagets disease

8
RISK FACTORS FOR BREAST CANCER

• Female sex
• Age
• Parity
• Family history
• Genetic factor
• Intermediate risk factors
• Early menarche, Late menopause
• Exposure to radiation
• Oral Contraceptives
• Smoking / Alcoholism / High fat diet
• Atypia /Hyperplasia
• Women on HRT

9
Groups

• Operable Breast Cancer T lt 5 cm,
• N0 or N1, Mo
• Large Operable Breast Cancer
• T gt 5 cm, N0 or N1, M0
• Locally Advanced Breast Cancer
• Metastatic Breast Cancer

10
Early Stages of Breast Cancer - Stage 0
11
Early Stages of Breast Cancer - Stage 1
12
Early Stages of Breast Cancer - Stage 2
13
Advanced Stages of Breast Cancer - Stage 3
14
Advanced Stages of Breast Cancer - Stage 4
15
Locally Advanced Breast Cancer

• Skin involvement oedema, ulceration,
• infiltration, satellite nodules
• Axillary Nodes Matted / Fixed
• SC/IMC (Ipsilateral)
• Chest wall fixity
• Arm Oedema

16
Operable Breast Cancer

• T/N Staging (Clinical)
• Histology (FNAC / Incision Bx)
• Bilateral Film Mammogram (for BCT)
• Eg/PgR (for NACT)
• Routine Pre Anesthetic Work up
• Metastatic Work up Not Recommended (lt 2 )
• STRONG CLINICAL SUSPICION OVERRULE NEGATIVE
• FNAC / MAMMOGRAPHY FOR EXCISION Bx

17
Operable Breast Cancer

• Surgical Options
• Breast Conservative Therapy (BCT)
• Wide Excision with Complete Axillary Clearance
• Modified Radical Mastectomy (MRM)

18
(No Transcript)
19
Lumpectomy
Lumpectomy Is the removal of the breast cancer
and a portion of normal tissue around the breast
cancer lump (the areas removed during the
surgery are shaded in green).
20
Lumpectomy
21
Simple Mastectomy
Total (or simple) mastectomy During a total
(or simple) mastectomy, the surgeon removes the
entire breast (including the nipple, the areola,
and most of the overlying skin) and may also
remove some of the lymph nodes under the arm
22
Simple Mastectomy
23
Modified Radical Mastectomy
24
Modified Radical Mastectomy
Radical mastectomy During a radical mastectomy,
the surgeon removes the entire breast (including
the nipple, the areola, and the overlying skin),
the lymph nodes under the arm
25
Quadrantectomy (Partial Mastectomy)
26
Quadrantectomy (Partial Mastectomy)
Partial (segmental) mastectomy Involves the
removal of the breast cancer and a larger
portion of the normal breast tissue around the
breast cancer (the areas removed during the
surgery are shaded in green).
27
Showing Upper Flap
Showing a specimen of Lumpectomy
28
After MRM
Showing Upper Lower Flap
29
Final Scar
Operated Specimen
30
Operable Breast Cancer

• Contraindications to BCT
• Multicentric disease (gt 1 quadrant)
• Extensive microcalcification on Mammogram
• Doubtful Compliance with RT
• Pregnancy (1st / 2nd Trimester and Precious
• child
• Cosmesis unsatisfactory

31
Models Histopathology Report

• Tumour Size (3 D), Type, Grade (MRB Score)
• Presence of Extensive Intraductal Carcinoma
  (EIC)
• Lymphovascular Embolisation
• Cut Margin Status
• No of Nodes ve / Total No. of Axillary Nodes
• Receptor Status ER and PgR

32
Adjuvant Therapy

• Systemic Hormone therapy and/or
  Polychemotherapy
• All women with N and/or 1 cm tumour
• ER or PgR ve ER PgR
  ve
• Premenopausal Chemotherapy
  Chemotherapy
• Hormonal therapy only
• Post menopausal Hormonal therapy Hormonal
  therapy
• /- Chemotherapy
  Chemotherapy
• B. Low Regional Radiotherapy
• All women with BCT
• All women with MRM with T gt 5 cm, gt 3 ve nodes

33
Locally Advanced Breast Cancer

• Core / Incisional Bx for diagnosis / receptor
  study
• Mammo Sonography Document tumour size
• Metastatic workup X-Ray Chest, USG Abdomen,
  LFT, Bone Scan
• Treatment Sequence NACT Surgery Adj. CT
• RT (Plus Tain If ERHC)

34
Locally Advanced Breast Cancer

• Surgical Options
• Clinical / mammography CR ? Index
  quadrantectomy
• with axillary clearance (BCT)
• PR (residual disease) ? a) BCT when feasible
  b) Simple mastectomy with
  axillary clearance (SMAC)
• SD or PD ? SMAC with or without reconstruction
• for skin cover
• PD and Inoperable ? Preop RT ? Reasses for
  Surgery

35
Follow Up After Primary Treatment

1. PE every 3 months x 2 years, biannually x 3
   years, then yearly
2. Mammography Annually
3. No other investigation in Asymptomatic patients
   Not cost effective, Does not prolong survival,
   Psychological harm

36
Follow Up After Primary Treatment

• Clinical recurrence or Symptoms s/o metastases
• X-ray Chest
• USG Abdomen
• LFT
• Bone Scan
• Skeletal Survey (Suspicious / weight bearing
  areas)
• CT / MRI as indicated

37
Breast Cancer Screening

• Periodic mammographic screening 30 Reduction
  in mortality in women gt 50 years
• No convincing evidence of benefit in women lt
  50 years
• Not sustainable in developing countries
• Physical Examination (PE) of breast by trained
  personnel
• Sensitivity 75 , Specificity gt 90
• ?? Alternative to Mammography
• 4) Breast Self Examination (BSE) may identify
  interval cancers early No survival benefit

38
Family History of Breast Cancer

• Confers 2-3 fold increased risk of developing
  breast cancer
• 5-10 of such women have an over 50 fold risk
• Related to mutations in BRCA 1 and BRCA 2 genes
• First degree blood relatives may be tested if
  these mutations confirmed in the index cases
• Negative Genetic testing does not eliminate risk
• Positive test cannot be remedied or prevented
  from being transmitted vertically
• Genetic testing provides information in a
  research setting but use in routine practice
  needs evaluation, social debate and counselling

39
EBM Guidelines

• Breast conservation therapy is the gold standard
  for Early Breast Cancer provided negative
  resection margins are achieved and an acceptable
  cosmetic result can be obtained
• Modified Radical Mastectomy remains the standard
  of treatment when disease is multicentric or
  compliance to postoperative radiotherapy is
  doubtful

40
EBM Guidelines

• Adjuvant Chemotherapy reduces death due to breast
  cancer by 25 (RR) in premenopausal women
• Effect is halved in postmenopausal women
• Adjuvant Tamoxifen reduces death in hormone
  sensitive breast cancer by 26 (RR) irrespective
  of menopausal status

41
EBM Guidelines

• Intensive investigations are not recommended
  to detect metastases during routine follow up
  of women after completion of primary treatment
  
• Investigate only when symptomatic

42
EBM Guidelines

• Screening Mammography alone is effective in
  saving lives in Post Menopausal Women
• Physical examination as effective one
  randomized trial
• Premenopausal Women Screening by Mammography
  and/or PE is debatable

43
Recommended Screening Tests for Women By Age
Groups (NCI)
Age Recommendation Benefit
Under age 40 Breast exam by doctor No data
Age 40 to 49 Breast exam by doctor Mammogram every 1 to 2 years May reduce her chances of dying from breast cancer by about 17 percent
Age 50 to 74 Breast exam by doctor Mammogram every 1 to 2 years May reduce her chances of dying from breast cancer by about 30 percent
Age 75 and above Breast exam by doctor Mammogram every 1 to 2 years No data
44
Ultrasound
Mammography
Needle (core) biopsy
45
(No Transcript)
46
Management of Metastatic Breast Cancer

• Main goal is palliation
• Hormone therapy (Based on ER-PR status)
• Tomaxifen 20 mg / Letrozole (2.5 mg)
• Oophrectomy premenopausal ER-PR
  second line treatment
• Chemotherapy ER-PR ve CAF, CMF, CEF
  paclitaxel
• Radiotherapy Bone metastases pain
  relief neurological skeletons.
  Complication of bone mets.
• Brain Metastasis - Relieving / Preventing
  neurological manifestation single
  multiple

47
Frequently Asked Questions (FAQs)

• Is everything in breast malignant ?
• Is there any non surgical Rx to breast
  malignancy ?
• What is hormone or chemotherapy ?
• When do they begin ?
• Are there any side effects with chemotherapy ?
• What are the advices given to the patient who
  is an chemotherapy by the doctor ?

48
Frequently Asked Questions (FAQs)

• Will there be any disturbances in the menstrual
  cycle ?
• Is hair loss permanent or not ?
• Will my breast be removed due to breast
  malignancy ?
• Are there any cosmetic procedure available
  after breast Sx ?
• What is radiation therapy and what are its side
  side effect ?

49
(No Transcript)
50
(No Transcript)
51
Role of Immuno - modulators in the cancer
treatment