Transcript Breast Cancer

Breast Cancer
Adapted From:
SEER’s Training Web Site
http://training.seer.cancer.gov.index.html
MCR Staff
Supported by a Cooperative Agreement between DHSS and the Centers
for Disease Control and Prevention (CDC) and a Surveillance Contract
between DHSS and MU
Background
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Excluding cancers of the skin, breast cancer is
the most common type of cancer in women in
the United States.
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Accounts for one of every three cancer diagnoses.
An estimated 174,480 new invasive cases of
breast cancer were expected to occur among
women in the United States during 2007.
About 2,030 new male cases of breast cancer
were expected in 2007.
Background
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The incidence of breast cancer rises after age
40.
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highest incidence (approximately 80% of invasive
cases) occurs in women over age 50.
62,030 new cases of in situ breast cancer were
expected to occur among women during 2007.
Approximately 88% will be classified as
ductal carcinoma in situ (DCIS).
Background
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2007 - estimated 40,910 deaths (40,460
women, 450 men)
Ranks second among cancer deaths in
women.
Mortality rates steadily decreased since 1990
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Larger decrease in women under 50
Due to combination of earlier detection &
improved treatment
Five-Year Survival Rates
(ACS Relative)
Stage 0
Stage I
100%
100%
Stage IIA
Stage IIB
Stage IIA
92%
81%
67%
Stage IIIB
Stage IV
54%
20%
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_breast_cancer_staged_5.asp
9/13/2007
Risk Factors
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Age—more prevalent in older women
Exposure to natural estrogens
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Affluence
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First childbirth after age 30
Age at menopause
Obesity—estrogens stored in body fat
High-fat diet
Alcohol consumption
Genetics/family history
Reducing Risk
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Having children at early age
Breast feeding
Healthy body weight
Exercise
Anti-estrogens
Symptoms
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New lump or mass
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painless, hard, uneven edges
sometimes tender, soft, or rounded
Swelling
Skin irritation or dimpling
Nipple pain or nipple turning inward
Redness or scaliness of the nipple or breast skin
Nipple discharge (other than milk)
A lump in the underarm area
Breast Anatomy
 Breast
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Made up of milk-producing glands
Supported and attached to the chest wall by ligaments
Rests on pectoralis major muscle
No muscle tissue
Layer of fat surrounds the glands and extends
throughout breast
 Three major hormones affect the breast
 Estrogen, progesterone, and prolactin
Breast Anatomy
Breast Anatomy
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Breast contains 15–20 lobes
Fat covers the lobes and shapes the breast
Lobules fill each lobe
Sacs at the end of
lobules produce milk
Ducts deliver milk to the
nipple
Anatomy – the lymphatic system
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Important to know if cancer has spread to the lymph
nodes
The more nodes involved, the more likely it is that
the cancer may involve other organs.
Affects treatment plan.
Anatomy – the lymphatic system
Most lymphatic vessels
in the breast connect to
lymph nodes under the
arm (axillary)
•Also internal mammary
nodes
•Supraclavicular or
infraclavicular nodes
Types of Breast Cancer
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The earliest form of the disease is ductal
carcinoma in situ,
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comprises about 15-20% of all breast cancers and
develops solely in the milk ducts.
Invasive ductal carcinoma,
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develops from ductal carcinoma in situ,
spreads through the duct walls, and
invades the breast tissue.
Most common – 70-80% of cases
Types of Breast Cancer cont’d.
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Cancer that begins in the lobes or lobules is
called lobular carcinoma.
 more likely to be found in both breasts.
 accounts for 10–15% of invasive breast
cancers.
Both ductal and lobular carcinomas can be
either in situ, or self-contained; or infiltrating,
meaning penetrating the wall of the duct or
lobe and spreading to adjacent tissue.
Types of Breast Cancer cont’d.
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Less common types of breast cancer include the following:
 Inflammatory
 Medullary carcinoma (originates in central breast tissue)
 Mucinous carcinoma (invasive; usually occurs in
postmenopausal women)
 Paget disease of the nipple
 Phyllodes tumor (tumor with a leaf-like appearance that
extends into the ducts; rarely metastasizes) and
 Tubular carcinoma (small tumor that is often undetectable
by palpation)
Inflammatory Carcinoma
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frequently involves entire breast
characterized by reddened skin
and edema caused by tumor
spread to lymphatic channels of
skin of breast
usually without an underlying
palpable mass
Is a clinical diagnosis verified by
biopsy of the tumor and
overlying skin.
Key words: lymphatic
involvement of skin, peau
d'orange, orange-peel skin, en
cuirasse
Image source:
National Cancer Institute
Paget’s disease
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Crusty tumor of nipple
and areola, which may
be associated with
underlying tumor of
the ducts.
www.sunmed.org/cbesk2.jpg
DCIS
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In Situ: Abnormal cells that have not escaped the
part of the body where they developed
For Breast – abnormal cells in the lining of a milk
duct that have not invaded surrounding breast tissue
Appearance of being precancerous when viewed
under a microscope, but
No ability to spread as cancer cells would
After DCIS, increased risk of invasive breast cancer
from 2 to more than 8 times higher than the risk
found in general population
Behavior
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Invasive (infiltrating)
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Synonyms for carcinoma in situ:
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In situ (15-20% of all breast
cancers)
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noninfiltrating,
intraductal,
lobular carcinoma in situ,
Stage 0, TIS
noninvasive,
no stromal involvement,
papillary intraductal,
papillary non infiltrating,
intracystic,
lobular neoplasia,
lobular noninfiltrating,
confined to epithelium,
intraepithelial,
intraepidermal,
DCIS, LCIS
Grade (differentiation)
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Assigned by pathologist
How close does the bx resemble normal tissue
Helps predict prognosis
Lower number indicates slower-growing
cancer that is less likely to spread
Higher number indicates a faster-growing
cancer that is more likely to spread
Grades
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Grade 1 (well differentiated) cancers have
relatively normal-looking cells that do not
appear to be growing rapidly and are arranged
in small tubules.
Grade 2 (moderately differentiated) cancers
have features between grades 1 and 3.
Grade 3 (poorly differentiated) cancers, the
highest grade, lack normal features and tend
to grow and spread more aggressively
Grade: Bloom-Richardson
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Bloom-Richardson (BR) Score
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Frequency of cell mitosis
Tubule formation
Nuclear pleomorphism
Bloom-Richardson Grade
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Low grade = BR score 3–5 = grade 1
Intermediate grade = BR score 6, 7 = grade 2
High grade = BR score 8, 9 = grade 3
Diagnosing Breast Cancer
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Mammogram
MRI
Ultrasound
Biopsy
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Fine Needle Aspiration
Core Needle Biopsy (stereotactic and other)
Excisional biopsy (sometimes with wire localization)
Lymph node dissection and Sentinel lymph node
biopsy
Sentinel Lymph Node Biopsy
A.D.A.M. illustration used with licensed permission.
Breast Cancer Staging (TNM)
Stage
Tumor (T)
Node (N)
Metastasis (M)
Stage 0
Tis
N0
M0
Stage 1
T1
N0
M0
Stage IIA
T0
N1
M0
T1
N1
M0
T2
N0
M0
T2
N1
M0
T3
N0
M0
T0
N2
M0
T1
N2
M0
T2
N2
M0
T3
N1, N2
M0
T4
any N
M0
any T
N3
M0
any T
any N
M1
Stage IIB
Stage IIIA
Stage IIIB
Stage IV
Source: American Joint Commission on Cancer and International Union Against Cancer
Treatment
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Surgery
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Mastectomy
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Lumpectomy
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Removal of axillary lymph nodes (for invasive cancers)
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Sentinel node biopsy
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Axillary dissection
Radiation
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Usually after surgery
Chemotherapy
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Combinations of drugs
Hormone therapy
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Tamoxifen, others
Estrogen & Progesterone
Receptor Status
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Proteins on the surface of cells that can attach to
substances such as hormones, that circulate in the
blood.
Normal breast cells & some breast cancer cells have
receptors that attach to estrogen and progesterone.
Play a role in the growth and treatment of breast
cancer.
ER-positive tumors have a better prognosis and are
more likely to respond to hormone therapy
About 2/3 breast ca contain at least one of these
Higher percentage in older women
Premenopausal: Tamoxifen
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Ovaries produce estrogen, sent through
bloodstream directly to the breast
Tamoxifen mimics estrogen
Attached to receptors, keeping real hormones
out
Postmenopausal: Aromatase inhibitors
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Produce most of their estrogen outside the
ovaries
Generated through androgen hormones store
in fatty tissue and adrenal glands
In a biochemical process started by the
enzyme aromatase, androgen is converted into
estrogen, into bloodstream and to breast
Aromatase inhibitors “block” the process
Aromatase Inhibitors (AIs)
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Steroidal AIs
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Aromasin (exemestane)
Nonsteroidal AIs
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Arimidex (anastrazole)
Femara (letrozole)
Many clinical trials showing significant results in
both reduced breast cancer relapse, as well as
reduced rates of metastatic disease
Now being studied in various scenarios with
Tamoxifen
HER2/neu Status
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human epidermal growth factor receptor 2
A protein involved in normal cell growth
Important in the control of abnormal or
defective cells that could become cancerous
HER2/neu positive cancers have an excessive
amount of the HER2/neu cancer gene protein
in and around their cells.
Herceptin
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Considered a targeted therapy or an immune
treatment
Given IV, once every 2-3 weeks
Targets the HER2 protein production
Helps stop the growth of the HER2 positive
cancer cells
Helps prevent recurrence
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http://www.cancer.gov/cancertopics/factsheet/therapy/herceptin
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Tests for HER2 Breast Cancer
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IHC: ImmunoHistoChemistry – measures the
production of the protein by the tumor.
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Ranked as 0, 1+, 2+ or 3+
3+ = HER2 positive cancer
FISH: Fluorescence In Situ Hybridization –
probes to look at the number of HER2 gene
copies in the tumor cell.
Treatment Options are changing
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Intraductal (in situ) – no longer recommend total
mastectomy (recent)
Treatment options may vary with age
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Brachytherapy (mammosite)
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Patients >45 or >50
Node negative
Small tumors
Combinations of tamoxifen/AIs
Avastin – new class of drug
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Blocks formation of blood vessels that supply tumors
Missouri Cancer Registry
Help Line: 800-392-2829
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Help interpreting path report for staging
http://mcr.umh.edu
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For further information, please contact:
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Sue Vest, Project Manager [email protected]
Nancy Cole, Assistant Project Manager
[email protected]