Breast Cancer Protocol

1
Breast Cancer Protocol

• Western Visayas Medical Center
• Hospital Cancer Committee

2
Breast Cancer Statistics

• Most common site-specific cancer in women
  worlwide
• 2nd most common cause of cancer death in women
• 5th most common cause of death in women
• 8-12 lifetime risk of developing breast cancer

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Breast Cancer (WVMC)

• Most common cancer in female being treated in
  the
• wards (20 surgical cases admitted for
  2008)
• Majority of patients in Clinical Stage IIb,
  III and stage
• IV
• Majority of patients in Pathologic stage III
• Treatment is mostly surgical
• Poor follow-up

4
Breast Cancer Symptoms

• Breast mass 33
• Others
• Nipple changes (retractions, discharges)
• Ulceration/erythema of the skin of breasts
• Breast enlargement/asymmetry
• Axillary mass

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Breast Cancer

• Early Detection

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Breast Cancer Screening

1. Breast self-exam (BSE) every month starting the
   age of 20. (1-2 weeks after 1st day of
   menstruation.
2. Clinical breast exam (CBE) starting the age of
   20 and every 3-5 years thereafter
3. Clinical breast exam at the age of 40 then yearly
   thereafter.
4. Mammography starting at the age of 40 then yearly
   thereafter.
5. Mammography at age 35 for high risk patients.

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Risk Factors in Breast CA

• Hormonal risk factors
• Early menarche
• Nulliparity
• Late menopause
• Obesity
• Hormonal pills/HRT
• Nonhormonal risk factors
• Old age
• First degree relatives with breast cancer
• Radiation therapy
• Alcohol consumption
• High fat diet

8
Survival Rate of Breast CA5-year survival rate

• I - 94
• IIa - 85
• IIb - 70
• IIIa - 52
• IIIb - 48
• IV - 18

9
Imaging Techniques

• Mammography - 30 reduction in mortality rate
  from breast cancer
• Screening mammography - women with no symptoms
• Diagnostic mammography - women with symptoms
• Breast Ultrasound adjunct to mammography
• Ductography - for women with bloody nipple
  discharges
• MRI - for high risk patients with dense breast
  during mammography

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Treatment of Breast CA

• Surgery
• Breast conserving surgery (lumpectomy,
  quadrantectomy)
• Mastectomy
• Modified radical mastectomy
• Chemotherapy
• Adjuvant chemotherapy
• Neoadjuvant chemotherapy
• Radiotherapy
• Hormonal therapy
• Antiestrogen (Tamoxifen) hormone receptor ()
  pre and postmenopausal
• 25 reduction in breast cancer recurrence
• 7 reduction in breast cancer mortality
• Aromatase inhibitors (anastrozole/letrozole)-
  hormone receptor () postmenopausal
• Biologic therapy- antiHER2/neu antibody therapy
  (herceptin/trasruzumab)
• Ablative endocrine surgery

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Breast cancer staging

• Stage I
• Primary tumor is 2 cms or less with no lymphatic
  spread
• Stage II
• IIa no tumor but 1-3 positive axillary nodes
  primary tumor is 2 cms or less with () 1-3
  axillary lymph nodes, () SLNB tumor 2-5 cms
  with no axillary spread
• IIb primary tumor is 2-5 cms with spread to 1-3
  axillary lymph node tumor gt5 cms with no
  axillary spread

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Breast cancer staging

• Stage III
• IIIa-no tumor but with 4-9 axillary lymph node
  lt5cms but with 4-9 axillary lymph node gt5 cms
  but does not grow into chest wall or skin
• IIIb-tumor has grown into chest wall and skin
  with no axillary lymph node or with 1-3 lymph
  node or 4-9 lymph node
• IIIc-tumor of any size with spread to 10 or more
  axillary lymph node or supraclavicular lymph node
• Stage IV
• Spread of breast cancer to distant areas of the
  body

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Breast Cancer

• Treatment Pathways

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Non- Palpable Breast Mass
History/PE
Normal Clinical Breast Exam, ltlow risk, lt40 yo
Doubtful clinical breast exam, high risk, gt40
years old
Breast Ultrasound/Mammography
Mammogram/Stereotactic needle not available
() lesions
(-) lesions
Image Guided Biopsy (Ultrasound/ mammography)
Observe
Malignant
Benign
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Palpable Breast Mass
Hx and PE
gt40 any size, high risk, lt40 but mass 2cm or more
lt40, lt2 cms in size, low risk
Biopsy (FNAB/Excision or incision biopsy)
Benign
Malignant
Non-invasive DCIS LCIS
Invasive Infiltrating Ductal CA, others
Observe
Complete excision if incision biopsy was done

• Clinical Staging
• Early Stage (I-IIIA)
• Late Stage (IIIB-IV)

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Early Breast Cancer (DCIS, Stage I,II,IIIA)
Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2
Mastectomy/Modified Radical Mastectomy
Breast Conserving Surgery (with axillary
dissection)
Axillary Nodes
High nuclear grade,high histologic grade, HER2
may proceed with chemotherapy
(-)
()
Chemotherapy
Radiotherapy
Observe
Hormone Receptor
Oophorectomy for premenopausal
()
(-)
Tamoxifen
HER2/neu () tumors may be started with Herceptin
Postmenopausal
Aromatase inhibitors
17
Advance Stage Breast Cancer (Stage IIIb-IV)
Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2,
hepatic UTZ, bone scan
Chemotherapy
Modified Radical Mastectomy/Mastectomy
Breast Conserving Surgery
Adjuvant Chemotherapy
Radiotherapy
Hormone Receptor ()
Tamoxifen
Aromatase inhibitors
Postmenopausal
HER2/neu () tumors may be started with Herceptin
18
Recurrent Breast Cancer (loc0regional and distant
metastasis)
Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2,
hepatic UTZ, bone scan
Biopsy (for local recurrence)
Chemotherapy
Radiotherapy
Hospice Care
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Sentinel lymph node biopsy

• Use for women with T1 and T2 N0 breast cancer
• () sentinel node biopsy
• Axillary dissection and node clearance necesary
• (-)sentinel node biopsy
• Axillary dissection not necessary

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Biomarkers

• Predict prognosis and response to therapy
• Predict more accurately the disease free and
  overall survival rate
• than clinicopathologic staging
• These tumors tend to grow faster and recur more
  often
• EGFr and HER2/neu overexpression signifies high
  nuclear grade
• and high proliferation aneuploidy
• Trastuzumab(Herceptin)
• 52 decrease in breast cancer recurrence

21
BRCA mutations

• BRCA-1 and BRCA-2
• Tumor suppressor gene
• BRCA-1
• 90 lifetime risk of developing breast cancer
• BRCA-2
• 85 lifetime risk of developing breast cancer
• Cancer prevention for BRCA mutation carriers
• Prophylactic mastectomy
• Prophylactic mastectomy and HRT
• Intensive suveillance
• Chemoprevention

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BCS vs Mastectomy

• Factors why women choose mastectomy over BCS
• Fear of recurrence in remaining breast
• Fear of dying from breast cancer
• High cost of radiation with BCS
• Distance from radiation facility
• Older women favor mastectomy

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Chemotherapy regimen

• Node negative women
• CMF
• FAC
• AC
• Node positive women
• FAC or CEF
• AC /- T
• A CMF
• CMF
• EC

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Thank you and good morning.