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Management of Management of Breast CancerBreast Cancer
ByByHussein M. KhaledHussein M. Khaled
Prof. Medical OncologyProf. Medical OncologyVice President Vice President
Post graduate Studies and ResearchPost graduate Studies and ResearchCairo UniversityCairo University
2
BREAST CANCERBREAST CANCERWorldwide incidence in females*Worldwide incidence in females*
*Incidence per 100,000 population.
Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
67.4
36.0
28.6
71.7
21.2
25.0
31.5
25.5
86.3
Eastern Eastern EuropeEurope
JapanJapan
Australia/Australia/New ZealandNew Zealand
South CentralSouth CentralAsiaAsia
Northern Northern AfricaAfrica
Southern Southern AfricaAfrica
Central Central AmericaAmerica
WesternWestern Europe Europe
NorthNorthAmericaAmerica
3
CANCER CONTROLCANCER CONTROL
EARLYEARLYDETECTIONDETECTION
DIAGNOSISDIAGNOSISPRIMARYPRIMARY
PREVENTIONPREVENTION
TREATMENTTREATMENT
4
BREAST CANCERBREAST CANCERSigns and symptoms at Signs and symptoms at
presentationpresentation Mass or painMass or pain
in the axillain the axilla
Palpable massPalpable mass ThickeningThickening PainPain
Nipple dischargeNipple discharge Nipple retractionNipple retraction
Edema or erythemaEdema or erythema
of the skinof the skin
5
6
BREAST CANCERBREAST CANCERDiagnosis pathDiagnosis path
Evaluationfor
biopsy
Cystaspiration
Biopsy•Excisional biopsy•Core-cutting needle biopsy•Fine-needle aspiration
Palpable mass
Ductalcarcinoma
in situ
Invasivecancer
Lobularcarcinoma
in situBenign
Insufficientevaluation,rebiopsy
If persistent, short-term follow-up
with surgeon
Continuedappropriatescreening
Cyst Normal
Nonpalpable mass
Treatment Path
Needlelocalization
7
Staging Classification of Breast Staging Classification of Breast TumourTumour
8
9
Early Breast CancerEarly Breast Cancer
10
11
12
NSABP B-06:NSABP B-06:Effect of Lumpectomy v. Mastectomy on SurvivalEffect of Lumpectomy v. Mastectomy on Survival
DIS
TA
NT
DIS
EA
SE
-FR
EE
SU
RV
IVA
L (
%) Cohort A Cohort B Cohort C
Total Mastectomy: 692/265 569/233 494/192
Lumpectomy: 699/302 634/282 520/236
No. of patients / No. of recurrences
YEAR
Lumpectomy + XRT: 714/278 628/253 515/204
13
14
HT
15
16
17
HER2 testing algorithmHER2 testing algorithm
Adapted from Bilous M, et al. Mod Pathol 2003;16:173–82Hanna W. Breast 2005;14(Suppl.1)S17 (Abstract 10)
+–
FISH/CISH
Patient tumoursample
IHC
2+ 3+1+0
+
FISH/CISH
+–
Herceptin®
therapy
Herceptin® therapy
Herceptin® therapy
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Locally Advanced Breast Locally Advanced Breast CancerCancer
19
20
21
22
23
24
25
26
What elements drive therapy decision making ?
Prognosis
Treatmentefficacy
Treatmenttoxicity
Co morbidity
27
ER +ER +
ER -ER -
ER +ER +
ER -ER -
T1a (0-5 mm)T1a (0-5 mm) T1b (6-10 mm)T1b (6-10 mm) T1c (11-20 mm)T1c (11-20 mm)
NCINCI
NCCNNCCN*)*)
St. GallenSt. Gallen
GUIDELINE RECOMMENDATIONFOR CHEMOTHERAPY FOR STAGE I BREAST CANCER
Not RecommendedNot Recommended OptionalOptional RecommendedRecommended
*) NCCN = National Comprehensive Cancer Network*) NCCN = National Comprehensive Cancer Network
28
www/Adjuvant on line !www/Adjuvant on line !
29
The The Breast Health Global Breast Health Global Initiative (BHGI)Initiative (BHGI)
Guideline Publication 2003Guideline Publication 2003
CONSENSUS STATEMENTSCONSENSUS STATEMENTS
Early Detection PanelEarly Detection Panel
Diagnosis PanelDiagnosis Panel
Treatment PanelTreatment Panel
30
BHGI GLOBAL SUMMIT BHGI GLOBAL SUMMIT 2005:2005:
Guideline StratificationGuideline Stratification
Breast J 2006;12 Suppl 1:S117-120
31
History
Physical examination
Clinical breast examination
Surgical biopsy
Fine-needle aspiration biopsy
Diagnostic breast ultrasound +/- diagnostic mammography
Plain chest radiography
Liver ultrasound
Blood chemistry profile / complete blood count (CBC)
Maximal
Stereotactic biopsy HER-2/neu status
CT scanning, PET scan, MIBI scan, breast MRI
Sentinel node biopsyIHC staining of sentinel nodes
for cytokeratin to detect micrometastases
Enhanced
Diagnostic mammography
Bone scan
On-site cytopathologistPreoperative needle localization
under mammographic or ultrasound guidance
Basic
Interpretation of biopsies
Cytology and/or pathology report describing tumor size, lymph node status, histologic
type, tumor grade
Limited
Determination and reporting of ER and PR status
Determination and reporting of margin status
Core needle biopsy
Image guided sampling (ultrasounographic +/-
mammographic)
Level of resources
Clinical Pathology Imaging and lab testsDiagnoDiagnosissis
32
Controversial Issues :Controversial Issues :
FNAC or Frozen SectionsFNAC or Frozen Sections 5 or 10 years of HT5 or 10 years of HT T and AIT and AI Type of CTType of CT Herceptin and othersHerceptin and others Pre or post op CTPre or post op CT Ov ablationOv ablation Cases who do not need systemic Cases who do not need systemic
treatmenttreatment
33
Cancer Treatment Cancer Treatment
S
Chemo. Radio.
Types of cancer treatment
Application of cancer treatment
Cost of cancer treatment
34
Situation AnalysisSituation Analysis Egypt Egypt
35
EGYPT
Gharbia Population–based registryGharbia Population–based registry
36
Rate per 100 000 pop.
Incidence Rates of Common Sites of CancerPopulation Data: Females
37.8
8.14.1 3.7 3.7 3.4 3 2.3 2.4
49.6
10.7
6 5.2 5 5.33.5 3 3.6
0
10
20
30
40
50
60
Breast NHL Liver Colon-Rectum
Ovary Bladder Brain&CNS Thyroid Lung
Crude Rate ASIR
37
GLOBAL STATISTICS:GLOBAL STATISTICS:Age-Specific Rates / 100,000 Females Age-Specific Rates / 100,000 Females
(all ages)(all ages)
Globocan 2002 (IARC)
38
The National Cancer The National Cancer InstituteInstitute
Cairo UniversityCairo Universitywww.nci.cu.edu.egwww.nci.cu.edu.eg
Cairo University National Cancer Institute
39
NCI Most Common Sites in Males NCI Most Common Sites in Males and femalesand females
40
National Cancer RegistryNational Cancer Registry
41
ProportionProportion Cumm. %Cumm. %
<35<35
35-35-
40- 40-
45-45-
50-50-
55-55-
60- 60-
65-65-
70+70+
7.77.7
12.612.6
14.814.8
17.617.6
16.216.2
10.410.4
11.211.2
5.05.0
4.54.5
7.77.7
20.320.3
35.135.1
52.752.7
68.968.9
79.379.3
90.590.5
95.595.5
100.0100.0
Age structure of Age structure of
Female breast cancer patients.Female breast cancer patients.
42
EgyptEgypt US SEERUS SEER
20-2420-24
25-2925-29
30-3430-34
35-3935-39
40-4440-44
45-4945-49
50-5450-54
…………
1.41.4
9.89.8
28.928.9
63.663.6
96.796.7
171.5171.5
181.2181.2
1.31.3
7.17.1
25.225.2
61.761.7
117.5117.5
192.1192.1
253.1253.1
Age-specific Incidence Rates of Breast cancerAge-specific Incidence Rates of Breast cancerin younger age groups: Egypt and US SEERin younger age groups: Egypt and US SEER
43
Magnitude of Breast Cancer in Magnitude of Breast Cancer in Egypt: 2025Egypt: 2025
Population size: 51 million females Population size: 51 million females Crude incidence rate: 55.1./100,000 femalesCrude incidence rate: 55.1./100,000 females Incidence: 14,000 Incidence: 14,000 28,000 breast cancer cases 28,000 breast cancer cases
Prevalence: 42,000 Prevalence: 42,000 84,000 breast cancer cases84,000 breast cancer cases
Magnitude of Breast Cancer in Magnitude of Breast Cancer in Egypt: 2050Egypt: 2050
Population size: 64 million females Population size: 64 million females Crude incidence rate: 68.8./100,000 femalesCrude incidence rate: 68.8./100,000 females Incidence: 14,000 Incidence: 14,000 44,000 breast cancer cases 44,000 breast cancer cases
Prevalence: 42,000 Prevalence: 42,000 132,000 breast cancer cases132,000 breast cancer cases
Projection of Magnitude of Breast CancerProjection of Magnitude of Breast Cancer in Egypt: 2025, 2050 in Egypt: 2025, 2050
44
Breast cancer T stage 1984 - 2006, Port Said, Breast cancer T stage 1984 - 2006, Port Said, EgyptEgypt
0
10
20
30
40
50
60
70
80
84-1985 86-1988 94-1999 2004 2005 2006
T1 T2 T3 T4
SOURCE: Prof. Dr. Ahmed Elzawawy
45
Cancer Control in Cancer Control in EgyptEgypt
46
Inflammatory Breast Cancer (IBC)Inflammatory Breast Cancer (IBC)
Swollen
Erythema
Peau d’Orange
Frequently Mistaken for Mastitis
Swollen
Erythema
Peau d’Orange
Frequently Mistaken for Mastitis
47
Clinico–Pathological Clinico–Pathological CorrelationCorrelation
in Breast Cancer Cases in Breast Cancer Cases (2002)(2002)
Revision of the slides of 212 patients.Revision of the slides of 212 patients. Only 16 patients had both clinical and Only 16 patients had both clinical and
pathological features of IBC (8%)pathological features of IBC (8%) Age distributionAge distribution
4 patients4 patients 35 yrs or less35 yrs or less
8 patients8 patients 45 yrs or less45 yrs or less
8 patients8 patients More than 45 yrsMore than 45 yrs
The youngest The youngest 25 yrs25 yrs
The oldest The oldest 76 yrs76 yrs
48
More than 90% of IBC showed positive axillary nodes.
IBC’s are characterized by:
High histologic grade tumors with high Nuclear grade, necrosis and high PCNA and MIB-1(Ki-67) labeling indices.
ER & PgR are frequently negative.
p53 > 70% positivity.
HER-2/Neu > 60%.
Biologic profile“ Immunphenotypic signature”
49
Tumor emboli and LYVE-1 and RhoC expression in IBC Tumor emboli and LYVE-1 and RhoC expression in IBC tumors from Egypt and the United Statestumors from Egypt and the United States
50
RhoC Scoring and Tumor Emboli for Egyptian patients with IBC and non-IBC
IBC (N=IBC (N=46)46)
No. (%)No. (%)
Non-IBC Non-IBC (N=(N=64)64)
No. (%)No. (%) PP-value-value
RhoC ScoreRhoC Score
11
22
33
4 4
1 (2)1 (2)
5 (10)5 (10)
2020 (44)(44)
20 (44) 20 (44)
24 (38)24 (38)
29 (45)29 (45)
7 (10)7 (10)
4 (6) 4 (6) <<0.00010.0001
RhoC CategoriesRhoC Categories
1-21-2
3-43-4 6 (13)6 (13)
40 (87)40 (87)53 (83)53 (83)
11 (17)11 (17) <0.0001<0.0001
Tumor EmboliTumor Emboli
Mean ± SDMean ± SD
0-10-1
2-82-8
9+ 9+
14.1 ± 14.014.1 ± 14.0
1 (2)1 (2)
1919 (41)(41)
26 (57) 26 (57)
7.0 ± 12.97.0 ± 12.9
32 (50)32 (50)
18 (28)18 (28)
14 (22 14 (22
<0.0001<0.0001
<0.0001<0.0001
51
52
53
Cairo University National Cancer Institute
Thank you
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