Transcript The Breast

Breast Cancer Update
Miss B.N. Shah
Consultant Surgeon
Ealing Hospital
Current Incidence of breast cancer
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Common disease
8% risk of development up to 74y
Varies between countries
Rare <20y
25 per 100,000 from 30-34y
200 per 100,000 from 45-50y
463 per 100,000 from 70-79y
Incidence by race
Bad news
• Commonest cause of death in women
aged 40-50y
• Second commonest cause of death from
cancer in women overall
• Only 20-50% at most, related to
attributable risk
Good news
• Breast cancer mortality has fallen both in
the UK and USA for the past decade
• 56% 5 year relative survival (1968-72)
• 70% 5 year relative survival (1988-92)
Mortality
anatomy
Lobule of the breast
Epidemiology
Influence of oral contraception (1)
• Weakly associated with breast cancer risk
• Single study evaluated effect on women
with F.H
• Cohort –showed R.R 3.3 among sisters
and daughters of probands
• Risk most evident before and during 1975
Influence of oral contraception (2)
• Population based studies don’t show this
effect
• Estimated excess number of cancers
between starting use and 10 years after
stopping 0.5-5%
• No hard evidence of increased risk of
having breast cancer diagnosed 10y or
more after stopping
Influence of HRT (1)
• Data more extensive , variable, many
confounding issues
• No long term RCT’s
• Collaborative group on Hormonal Factors
in Breast Cancer
• Meta-analysis of 90% of world data
• 54,000 women, 33% had used HRT for 5 y
or more
Influence of HRT (2)
Two main consistent findings
1. The length of time on HRT was related to
extra breast cancers in users
2. This increased risk disappears within 5y
of stopping
• Women who use HRT for a short time
around the menopause have a very low
excess risk
Influence of HRT…..nitty, gritty
Cumulative incidence for women aged 5070y is 45 per 1,000 in ‘never users’
• 2 per 1,000 extra cancers after 5yrs on
HRT
• 6 per 1,000 extra cancers after 10yrs
• 12 per 1,000 extra cancers after 15yrs
HRT…what to do?
• RCTs in UK, Italy, Scandinavia and
Canada
• Each patient treated on their own merit
• Apply the principle of ‘ treatment tailored
strategies’
Genes and hereditary factors (1)
• Susceptibility genes responsible for only 510% of breast cancers
• great strides in characterising genes
responsible
• Almost nothing known about various gene
interactions +/- environmental factors
Genes and hereditary factors (2)
• 1990 BRCA1 (17q) responsible for 90% of
cases with autosomal dominant
transmission of breast cancer and ovarian
cancer
45% in breast cancer alone
• BRCA2 (13q)
Genes and hereditary factors (3)
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Hereditary breast cancer
Onset <45y
excess bilateral cancer
Multiple primary cancer
80% BRCA1, 20% BRCA2
Ashkenazi 1:100 risk of breast
/ovarian/both
Screening useful
Genes and hereditary factors
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Familial breast cancer
Positive FH
1 or more 1st or 2nd degree relatives that
do not fit the HBCa category
Risk ratios increase with the number of
affected relatives
Quantitative risk assessment helpful
Genetic testing not yet feasible
Genes and hereditary factors (3)
Multiple cancer syndromes
• Li-Fraumeni syndrome (p53 mutation)
• Cowden ‘s disease (mutation of PTEN
gene)
• Ataxia Telangectasia (11q)
The future
• Rapid progress – clinical and molecular
genetics
• find ways to cost DNA testing
• ?legislaton to prohibit discrimination
‘genetic labelling’- employers,insurance
companies etc.
GP practice
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The Department of Health point out that a GP with a list of 2000 patients is likely to
see only one woman a year who has breast cancer. But they will see a lot more
women who have non-cancerous breast conditions such as
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Cysts - sacs of fluid in the breast tissue and most common in the 40-60 year age
group
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Fibroadenomas – a collection of fibrous glandular tissue and most common in 20-30
year age group
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Diffuse nodularity – ‘lumpy’ breasts, which are common in all age groups up to the
age of 50
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Breast pain – this is not a common symptom of breast cancer
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Although 9 out of 10 breast lumps are not cancer, the Department of Health
recommends that any woman over 30 who has a lump in the breast that does not go
away should be examined by her GP.
Early referral
• A distinct lump in women under 30
• ‘Lumpy’ breasts that do not go away after a period has finished
• A sore infected area on the breast (abscess)
• Recurrent cysts
• Breast pain that does not go away with reassurance, painkillers
prescribed by your GP and wearing a well supporting bra
• Any type of nipple discharge in women over 50
• Any woman under 50 who has a blood stained discharge or a
discharge from both nipples that is enough to stain clothing
Guidelines for Urgent Referral
• The symptoms that need urgent referral in 2 weeks for possible
cancer of the breast are
• An area skin on the breast that is inflamed and sore (ulcerated)
• Small lumps that appear just under the skin nodules - these are
often shiny and red
• Dimpling or distortion of the skin, called peau d'orange
• A rash on a nipple or surrounding area called nipple eczema
• Nipples that have turned in (inverted) within the past 3 months
Imaging
• Ultrasound
(U)
• Mammagram (M)
1- normal
2 - benign
3 - probably benign
4 - probably malignant
5 - malignant
Cytology
C1 - inadequate sample
C2 - definitely benign
C3 - probably benign
C4 - probably malignant
C5 - malignant
Core Biopsy
B1 - normal
B2 - benign
B3 - probably benign
B4 - probably malignant
B5 - malignant
Management of a lump
LUMP
under 35 years
clinical assessment
P1-5
ultrasound
U 1-5
cytology
C 1-5
Management of a lump
under 35 years
benign
patient choice
excise
cosmetically
observe
repeat T. A.
core biopsy
Management of a lump
over 35 years
lump
clinical
p 1-5
mammogram
ultrasound
M 1-5
U 1-5
core biopsy
FNAc
B1-5
C1-5
Management of a lump
over 35 years
malignant
Intraductal carcinoma
surgery
axillary procedure
neoadjuvant
chemotherapy
then surgery
?reconstruction
primary
delayed
Management of a lump
malignant
DCIS
surgery
DXT
no clearance
sentinel node
primary reconstruction
Lymphatic drainage
Management of the axilla
Clearance
Levels,1, 2, 3
Sample
4 nodes
Sentinel node
50:50 divide
Sentinel Node axillary dissection
• Guided localisation
• minimally invasive alternative to traditional
axillary dissection
• Blue dye
• Radioisotope
• <5% false negative
• The future
Screening (U.K.)
• Two view
• Double reading
• 50-65years
• 3 yearly
UK Trial of early detection of
breast cancer
• 1999
• 27% decreased breast cancer mortality
• 45 – 60years
• Supports Edinburgh trial (21%)
Anatomy