Transcript Breast Cancer Awareness

Breast Cancer Awareness
Kristen Deep
Jennifer D’Onofrio, BS, FNP-S
Kelly Strine BS, RN, FNP-S
Objectives
• To develop an adequate understanding of
screening guidelines according to the U.S.
Preventive Service Task Force (USPTF)
and the American Cancer Society.
• Distinguish difference of benign versus
malignant breast conditions.
• Identify patients that should be screened
for genetic testing
• Identify three community resources
available for breast cancer patients
What is breast cancer?
• Malignant tumor
that originates from
breast epithelial
cells, glandular
cells, or connective
tissue.
• Most common in
women, but may be
found in men.
(American Cancer Society, 2014)
Types of breast cancer
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Ductal carcinoma in situ
Invasive infiltrating ductal carcinoma
Invasive lobular carcinoma
Inflammatory breast cancer
Paget’s disease of the nipple
Phyllodes tumor
Angiosarcoma
(American Cancer Society, 2014)
Ductal carcinoma in situ
• Non-invasive or pre-invasive cells that
line the ducts have changed to look like
cancer cells.
• Cells have not spread through the walls
of the ducts into surrounding breast
tissue.
(American Cancer Society, 2014)
Invasive/Infiltrating ductal carcinoma
• Most common type of breast cancer.
About 8/10 breast cancers are this type.
• Starts in the milk duct of the breast. Tumor
breaks through this milk duct and invades
the fatty tissue of the breast.
• Able to spread to other parts of the body
via the lymphatic system or bloodstream.
(American Cancer Society, 2014)
Invasive lobular carcinoma
• Begins in the milk producing glands,
also known as lobules.
• This can also spread to other areas of
the body.
• May be harder to detect through
mammogram.
(American Cancer Society, 2014)
Inflammatory breast cancer
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Invasive
Uncommon, 1-3% of all breast cancers
No single lump or tumor
Caused by cancer cells blocking lymph vessels
on skin.
• Makes skin on the breast look red and feel
warm.
• Breasts may be larger, firmer, tender, or itchy.
• Skin may also be thick and have peau d’orange
texture.
(American Cancer Society, 2014)
Paget’s disease of the nipple
• Rare, 1% of all breast cancer cases
• Starts in the breast ducts and spreads
to the skin of the nipple and then to the
areola.
• Nipples and areolae may appear crusty,
scaly, red, and have areas or bleeding
or oozing.
(American Cancer Society, 2014)
Phyllodes tumor
• Develops in the stroma, which is the
connective tissue of the breast.
• Usually benign, but it may turn
cancerous.
(American Cancer Society, 2014)
Angiosarcoma
• High grade tumor that is aggressive and fast
growing.
• Starts in cells that line the blood or lymph vessels.
• Rarely occurs in the breast, but when it does it
develops due to previous radiation treatments.
• May develop 5-10 years after radiation therapy.
• Can look like a skin infection, a bruise or lesion that
will not heal.
• May also present as a soft lump that can be felt or
seen.
(American Cancer Society, 2014, Tunstall, 2012)
Clinical Presentation
• Breast lump or area
that feels denser
(may or may not have
pain)
• Tenderness
• Dimpling
• Nipple retraction
• Nipple ulceration
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Erythema
Peau d’orange
Change in breast shape
Breast enlargement
Alteration in vein
pattern of breast tissue
• Nipple discharge
• One or more palpable
enlarged axillary lymph
nodes
(Hollier & Hensley, 2011)
Non cancerous breast conditions
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Fibrocystic breast disease
Intraductal papilloma
Fibroadenoma
Mastitis
Hyperplasia
Adenosis
Duct ectasia
(American Cancer Society, 2014; Hollier & Hensley, 2011)
Fibrocystic breast disease
• Benign breast disorder
• Assessment findings
– Palpation of smooth, moveable masses
– Breast pain or tenderness that diminishes after
menses.
– Breast engorgement
– Breast thickening
– Worsening of symptoms premenstrually
– Nipple discharge of varying color and consistency.
(Hollier & Hensley, 2011)
Intraductal Papilloma
• Benign tumor within the ductal system
of the breast
• Assessment findings
– Bloody or serous nipple discharge
– Usually unilateral unless multiple ducts are
involved.
(Hollier & Hensley, 2011)
Fibroadenoma
• Benign tumor containing fibrous tissue
• Commonly occurs in women in 20’s-30’s
• Use of birth control pills before age 20 liked to
risk of fibroadenomas
• Assessment findings
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Single, nontender, firm mass
Multiple lesions in 10-15% of cases
Freely moveable
No change in mass with menstrual cycle
No nipple discharge
(American Cancer Society, 2014; Hollier & Hensley, 2011)
Adenosis
• Breast lobules are enlarged and
contain more glands than usual.
(American Cancer Society, 2014)
Mastitis
• Plugged milk ducts, which lead to infection
• Most common in women who are
breastfeeding
• Assessment findings
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Breast tenderness and pain
Lump in one or both breasts
Fever, chills
Erythema overlying sore area
Flu-like symptoms
Fatigue
(Hollier & Hensley, 2011)
Hyperplasia
• Also known as proliferative breast
disease
• Overgrowth of cells that line the ducts
or lobules
• Can be usual or atypical
(American Cancer Society, 2014)
Duct Ectasia
• Common in women over 50
• Occurs when breast ducts widen and
thicken. This leads to blockage, which
leads to fluid build-up.
(American Cancer Society, 2014)
Incidence
• The American Cancer Society
estimated in 2012 that 226,870 new
cases of invasive breast cancer and 63,
300 in situ cases would have been
diagnosed.
• The second leading cause of death
among women
• Lifetime risk of developing of breast
cancer in the U.S. is 12.15% or 1 in 8
women.
Magnus, Ping, Shen, Bourgeoi, & Magnus, 2011;Mahon, 2012
Incidence
• Women greater than 65 years of age
have a six times greater risk of
diagnosis
• If rate remains unchanged an estimated
80 million women will be diagnosed
with breast cancer by the year 2050
• Increase of 72 percent
Ravert & Huffaker, 2010
Early Detection
• Early detection is crucial for decreasing
mortality rates.
• Routine screening is fundamental in
detecting breast cancer at an early
stage, thus decreasing overall mortality
rate.
• Estimated a 25-30 percent reduction in
women aged 50-69 and 17 percent
reduction in women aged 40-49
mortality rate
Risk Factors
• According to the USPTF risk factors
women age 40-49:
– Breast density
– Family history (First degree relative or genetic
mutation BRCA-1 or BRCA-2)
– Reproductive history
– Prior diagnosis of benign breast conditions
– Physical Activity
– Alcohol and Smoking Use
– BMI
– Race and Ethnicity
Risk Factors
• USPTF conducted a systemic review
and meta-analysis of risk factors in
women aged 40-49 years
• Objective was to identify women at a
two-fold increased risk to determine
when to begin screening
• Determine benefit of earlier screening
(number of life-years gained) versus
harms (false-positives)
Risk Factors
2.0 Fold Increased Risk
• Extremely dense
breast tissue
• First degree
relative
• Risk increases if
two or more first
degree relatives
diagnosed before
age 40
1.5-2.0 Fold Increased
Risk
• Prior benign
breast result
• Second degree
relative
• Dense breast
tissue
Nelson, et al. 2012
Risk Factors
1.0-1.5 Increased Risk
Lower than Average Risk
• Current use of oral
contraceptives
• Nulliparity
• Age of 30 at birth of
first child or older
• BMI 25 or greater
• Low breast tissue
density
• Age 15 or older
onset of menarche
• Three or more
children
• Breastfeeding
• Menopausal Status
• Hormonal therapy
Nelson, et al. 2012
Risk Factors
• A positive family history is essential in
determining if genetic counseling and
mutation testing need to occur
– Consider medication to reduce risk
• Increasing age is an important risk
factor
• There is a risk of diagnosis even when
no potential risk factors are identified
Nelson, et al. 2012; USPTF, 2012
Screening
Guidelines
Screening
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Clinical breast examinations
Self-breast examinations
Mammography
MRI
Breast Examinations
• Lack of reliability in using only clinical
and self breast examinations as
detection methods
Mammography
• Considered the GOLD standard for early
detection of breast cancer
• An x-ray of the breast
• Screening: asymptomatic
– 2 view
• Diagnostic: symptoms or abnormal
screening.
– More views
Mammography
• False-positives occur more in younger
women compared to older women
related to breast density.
– Increased anxiety/psychological harm
– Additional medical visits
– Additional imaging
– Biopsies
– Un-necessary treatment
– Radiation Exposure
USPTF, 2012
USPTF: Mammography
• According to the USPTF Recommendation:
– Women aged 40-49: Individualized decision to
initiate biennial screening (Grade C)
– Women aged 50-74: Every 2 years (Grade B)
– Women aged 75 or greater: No recommendation
USPTF: Mammography
• For women greater than 40 years of
age who have no known genetic
mutation or positive family history.
• Biennial screening is optional.
• Greater reduction in mortality women
aged 50-74 than younger women.
• False-positives are higher in younger
women
• Over-diagnosis with increasing age
Digital Mammography
• Increase of accuracy for premenopausal or perimenopausal women
• Increase of accuracy for dense breast
tissue
• Uncertain if over-diagnosis occurs more
with digital mammography versus film
mammography
• More expensive than film
mammography
Mahon, 2012; USPTF, 2012
American Cancer Society
• Beginning in 20’s, women should be educated on
performing self-breast examinations and to report any
new symptoms
• Clinical breast examinations: Every 1-3 years for women
aged 20-39 and annual for women 40 and greater, prior
to mammography
• Mammography: annually at age 40 with no specific age
to stop. Benefits versus risk need to be considered to
determine age when to discontinue regular screening
• MRI: 20-25% or higher lifetime risk associated with
positive family history (breast or ovarian cancer),
genetic mutation, or chest radiation. Begin at age 30
– In addition to yearly mammogram
Summary
• USPTF: Recommendation for biennial
mammograms for women greater than 40
years old based on individual.
• USPTF: Mammograms every two years for
women greater than 50 years
• American cancer society recommends
annual screening for women 40 years and
greater
• American cancer society offers educational
information on web-site for patients
Genetic Testing
Genetic Testing
• What are BRCA 1 and BRCA 2?
– Genes that produce tumor suppressor
proteins.
• It is estimated that 2-7% of breast
cancers and 10-15% of ovarian cancers
are results of BRCA1 and BRCA 2
mutations.
Breast Cancer Risks
• In the general population, 12% of
women will develop breast cancer in
their lives.
• If a harmful BRCA1 mutations is
inherited that risk increases to 55-65%.
• If a harmful BRCA2 mutation is
inherited, that risk increases to 45%.
Ovarian Cancer
• In the general population, 1.4% of
women will develop Ovarian Caner in
their lives.
• In those with an inherited BRCA1
mutation this risk is increased to 39%.
• In those with an inherited BRCA2
mutation, this risk is increased to 1117%.
Who Should Have Genetic Testing
• BRCA 1 & 2 gene mutations are
relatively rare in the general population.
• Testing should be performed only when
the family history suggests possible
harmful mutations.
• BRST Screening Tool
www.breastcancergenescreen.org
Negative Test Results
• If a close first or second degree relative is
known to have a harmful BRCA 1 or 2
mutation and the patient is negative, this
means the test is negative and it cannot be
passed along to their children.
• If there is a possibility of a harmful mutation,
but no mutation has been identified in the
family, the results are less clear.
Positive Test Results
• A positive results indicates that a known
harmful gene mutation of BRCA1 or 2 is
present and there is an increased risk of
developing cancer.
• The genetic mutation has a 50% chance of
being passed down to sons or daughters.
• Siblings of BRCA 1 or 2 known gene
mutations have a 50% chance of being
positive for the mutation.
Ambiguous Test Results
• Tests results described as ambiguous
have been identified as genetic variant
of uncertain significance.
Other Considerations
• What would I do if I knew I was positive
for the gene that could cause Breast or
Ovarian Cancer?
• What would I do if my results were
found to be negative?
• What would I do if my results were
found to be ambiguous?
Case Study
• Mandy, a 24 year old Caucasian female
arrives to the office inquiring about BRCA
testing. She tells you that her aunt who is
49, is currently battling breast cancer and
she is concerned about her risks for
developing breast cancer. There is no family
history of ovarian cancer. No other family
members have been tested previously for
BRCA 1 or 2. Her age of menarche is 14.
She is married with 1 child. How should you
counsel this patient?
Case Study
• Sydnie is an 18 year old female who is starting college in the
fall. When Sydnie was a couple of months old, her mother was
diagnosed with Breast Cancer at the age of 26. Her mother
underwent a unilateral mastectomy with lymph node removal,
chemotherapy and radiation. Five years later she was in
remission. Syndie’s maternal grandmother was also diagnosed
with cancer around this time. She underwent treatment as well.
Sydnie’s mother had another child when she was 8 years old.
Within a year, her mother was diagnosed with recurrent breast
cancer. When Sydnie was 13, her mother passed away at the
age of 39. One month later, her Grandmother passed away.
Sydnie’s first age of menarche was 14. There is no known
history of ovarian cancer. Sydnie’s Aunt, her mother’s sister, is
alive and well and her uncle, her mother’s brother, is alive and
well. What type of counseling would you provider this patient?
Referrals
• Patients with several risk factors for
BRCA1 or BRCA2 mutations should be
referred to a Genetic Counselor.
– https://www.health.ny.gov/diseases/cancer
/genetics/genetic_counselors.htm
– https://www.breastcancergenescreen.org/d
efinitions.aspx
– Bonnie R. Braddock
Senior Certified Genetic Counselor
Upstate Medical University
750 E Adams St
Syracuse, NY, US 13210-2342
(315) 464-6395 (phone)
Resources
• Susan G. Komen
http://ww5.komen.org/Default.aspx
• American Cancer Society
http://www.cancer.org/
• New York State Cancer Services
Program
https://www.health.ny.gov/diseases/c
ancer/services/
References
American Cancer Society (2014). Breast cancer: Early detection. Retrieved from
www.cancer/org/cancer/breastcancer/moreinformation/breastcancerearlydetection/index
American Cancer Society (2014). Types of breast cancer. Retrieved from
http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-breast-cancer-types
Bellcross C 2014 Breast Cancer Genetics Referral Screening Tool. Retrieved from
https://www.breastcancergenescreen.org/201403012213071011244655
Centers for Disease Control and Prevention (2013). Geenetic Counseling and Evaluation for BRCA1/2 Testing. Retrieved from
http://www.cdc.gov/genomics/resources/diseases/breast_ovarian_cancer/counseling.htm
Hollier, A. & Hensley, R. (2011). Clinical guidelines in primary care: A reference and review book. Lafayette, LA: Advanced
Practice Education Associates, Inc.
Magnus, M., Ping, M., Shen, M.M., Bourgeois, J., & Magnus, J. (2011). Effectiveness of mammography screening in reducing
breast cancer mortality in women 39-49 years: A meta-analysis. Journal of Women’s Health, 20(6), 845-852.
DOI:10.1089/jwh.2010.2098
Mahon, S. (2012). Screening for breast cancer: Evidence and recommendations. Clinical Journal of Oncology Nursing, 16(6),
567-570. DOI: 10.1188/12.CJON.567-571.
National Cancer Institute at the National Institutes of Health (2014) BRCA1 and BRCA2: Cancer risk and
genetic testing Retrieved from
http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA201403012220201474938393
National Society of Genetic Counselors (n.d.). Find a genetic counselor. Retrieved from
http://nsgc.org/p/cm/ld/fid=164201403012214251193767309
Nelson, H., Zakher, B., Cantor, A., Fu, R., Griffin, J…Miglioretti, D. (2012). Risk factors for breast cancer for
women aged 40-49 years. Annals of Internal Medicine, 156 (9), 635-648.
New York State Department of Health (2013) New York State Clinical Geneticists and Genetic Counselors:
Caner Genetics. Retrieved from
https://www.health.ny.gov/diseases/cancer/genetics/genetic_counselors.htm201403012210041167124391
Ravert, P. & Huffaker, C. (2010). Breast cancer screening in women: An integrative literature review. Journal of
the American Academy of Nurse Practitioners, 22, 668-673. DOI:10.1111/j.1745-7599.2010.00564.x
Susan G Komen Retrieved from
http://ww5.komen.org/BreastCancer/RecommendationsforWomenwithHigherRisk.html#BRCA20140301221749
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Tunstall, B. (2012). What is angiosarcoma? Retrieved from http://sarcomahelp.org/angiosarcoma.html
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US Preventive Services Task Force 2013 Risk assessment, genetic counseling, and genetic testing for
BRCA-related cancer in women Retrieved from
http://www.uspreventiveservicestaskforce.org/uspstf12/brcatest/brcatestfinalrs.htm2014030122112319698
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