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Breast Cancer Awareness Day

OBJECTIVES

• Epidemiology• Risk factors• Different types of breast cancer• Breast cancer characteristics• Breast cancer staging• Breast cancer screening• Breast cancer treatment• Survivorship

Breast Cancer

• Breast cancer is the most common cancer in women worldwide. It is estimated that more than 1.6 million new cases of breast cancer occurred among women worldwide in 2010.

• The second cause of death from cancer in women in North America after lung cancer.

• When diagnosed early, it can be treated with surgery, radiation and systemic therapy including chemotherapy and hormonal therapy.

• At the time of diagnosis more than 90% of patients have localized disease.

• The average age at diagnosis for women is 61 (61 for white women and 57 for African American women).

• It is more common in women ages 50 and older.

Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis. Lancet. 2011 Sept 15

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Epidemiology

• In the United States, an estimated 230,000 new cases of invasive breast cancer are diagnosed yearly.

• Approximately 40,000 new cases of noninvasive breast cancer (ductal carcinoma in situ; DCIS) is diagnosed every year.

• Approximately 2000 cases of male breast cancer is diagnosed in men each year.

• Lifetime risk of developing breast cancer in North American women with life expectancy of 85 years is one in eight.

• The incidence of breast cancer increases with age, but the rate of increase in incidence slows after menopause.

• The average 5-year survival rate of all patients with breast cancer is 87.5%

If current age is: Absolute risk of developing breast cancer in the next 10 years is:

20 1 in 1,760 (0.06%)

30 1 in 229 (0.4%)

40 1 in 69 (1.4%)

50 1 in 42 (2.4%)

60 1 in 29 (3.4%)

70 1 in 27 (3.7%)

USA2011

Women Men

Number of new breast cancers diagnosed

230,480 2,140

Number of deaths 39,520 450

Figure 1.5: Estimated New Cancers among Women by State, 2004-2008

State

Rate of Invasive Breast Cancer (per 100,000

women)

State

Rate of Invasive Breast Cancer (per 100,000

women)

Arizona 107 Connecticut 136

Michigan 120 Montana 120

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White(non-

Hispanic)

African American

Hispanic/Latina

Asian and Pacific

Islander

Native American

and Alaskan Native

Incidence rate 137 per

100,000

122 per 100,000

79 per 100,000

98 per 100,000

79 per 100,000

American Cancer Society, 2011

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Lifetime risk of breast cancer worldwide

Source: Forouzanfar et al.

SEER Cancer Statistics Review,1975-2008, 2011

Breast Cancer Racial Disparities

• Breast cancer incidence in African American women is lower than Caucasian.

• Breast cancer mortality is 39 percent higher. From 1999-2006, the five-year relative survival rate for breast cancer among African American women was 78 percent compared to 90 percent among Caucasian women. Factors that may all play a role include: – Biologic and genetic differences in tumours

– Presence of risk factors

– Barriers to health care access

– Health behaviours

– Later stage of breast cancer at diagnosis

• Breast cancer screening rate are similar.

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Risk Factors• Personal history of breast cancer

• BRCA1 and BRCA2 gene mutations or mutation in the TP53 or PTEN genes (Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome).

• Strong family history (BC in1st degree relative <40 y/o)

• Increasing age

• Early menarche (<12 years) and late menopause (>55)

• Nulliparity, first birth after the age of 30

• Weight gain

• Ductal carcinoma in situ, atypical lobular hyperplasia or atypical ductal hyperplasia

• Prior breast biopsies

• Alcohol

• Long-term hormone replacement therapy (E+P> E) or birth control pills

• Exposure to ionizing radiation to the chest

• Low vitamin D level

Alcohol

• Having a few alcoholic drinks each week modestly increases the risk of breast cancer.

• The more a woman drinks, the higher her risk of breast cancer

• A pooled analysis of data from 53 studies found for each alcoholic drink consumed per day, breast cancer risk increased by about seven percent .

• Women who had two to three alcoholic drinks per day had a 20 percent higher risk of breast cancer compared to non-drinkers.

Br J Cancer. 87(11):1234-45, 2002

Alcohol and Breast Cancer

• Alcohol contains a lot of calories leading to weight gain that can cause higher blood levels of estrogen which is linked to an increased risk of breast cancer.

• Some studies have shown that alcohol can increase the risk of breast cancer independent of body weight. Alcohol affects the way body processes estrogen, causing estrogen levels to rise.

J Natl Cancer Inst. 94(8): 606-616, 2002

Am J Epidemiol. 170(3):308-17, 2009

Cancer Epidemiol Biomarkers Prev. 12(2):161-4, 2003

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Types of Breast Cancer

• Non-invasive: An abnormal growth of cells within the area in which it started:– Ductal Carcinoma in situ (DCIS): Stage 0

– Lobular carcinoma in-situ (LCIS): A risk factor for breast cancer.

• Invasive: When breast cancer cells spread into surrounding breast tissue from the ducts or lobules.

Invasive Breast Cancer

• Infiltrating ductal carcinoma (70-80%)

• Infiltrating lobular carcinoma (5-10%)

• Medullary breast cancer (1.2%)

• Mucinous (1-2%, favorable prognosis)

• Micropapillary (1%, tendency for LN metastasis)

• Tubular (2%, favorable prognosis with rare metastasis)

• Metaplastic (fewer T1, less LN involvement, HR negative, more poorly differentiated)

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Breast Cancer Characteristics

• Size: In general, the smaller the tumor, the better the chance for successful treatment

• Grade: I – III

• Hormone receptor(ER, PR) and HER2/neu receptor status

• Spread:

– Local: The breast cancer is confined within the breast

– Regional: The breast cancer has spread to the lymph nodes (mainly axillary nodes)

– Distant: The breast cancer has spread to the other organs

Breast Cancer Staging

• The stages of breast cancer range from 0 to IV (0 to 4). Stage depends on the combination of: – T (Tumor size)

– N (Lymph Node Status)

– M (Metastases)

• Stage I: T0-1, N0-1mi, M0

• Stage II: T0-3, N0-1, M0

• Stage III (Locally Advanced Breast Cancer): – T0-4, N0-3, M0

• Stage IV: Any T, Any N, M1

Breast Cancer Staging and Survival

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Metastatic Breast Cancer

• Metastasis occurs when breast cancer cells break away from the breast tumor and spread to other organs through either the blood stream or the lymphatic system

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Breast Cancer Screening

• Starting at age 40, all women should get a mammogram every year.

• Under age 40 with either a family history of breast cancer or other concerns about breasts mammograms or other tests, such as breast MRI is indicated.

• Clinical breast exam at least every 3 years starting at age 20 and every year starting at age 40.

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Other Screening Methods

• Magnetic resonance imaging (MRI)– American Cancer Society and the National

Comprehensive Cancer Network currently recommend women with a BRCA1 or BRCA2 genetic mutation get an MRI in combination with their annual mammography screening

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Treatment of Breast Cancer

Survivorship

• Definition: A person having no cancer after completion of his/her treatment or the process of living with, through and beyond cancer.

• It begins when a person is diagnosed with cancer

• It includes people who continue to have treatment to reduce their risk of recurrence or to manage the disease over a long time

• There are about 12 millions of survivors in the United States

• Acute survivorship: When a person is being diagnosed and/or is in treatment

• Extended survivorship: The time right after the treatment is completed

• Permanent survivorship: Describes a longer period since the treatment is completed

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Survivorship Challenges

• Psychological challenges

• Physical challenges

• Sexual and reproductive challenges

• Relationship challenges

• Work-related challenges

• Financial challenges

• Spiritual challenges

Resources available to survivors

• Family counseling

• Genetic counseling

• Home care services

• Individual/couple counseling

• Nutritional planning

• Occupational therapy

• Oncology social workers

• Physical therapy

• Pain management

• Recreational therapy

• Support groups

• Survivor matching programs

• Vocational counseling

Survivorship Resources

• www.ucscsn.org

• www.carepages.com

• www.mylifeline.org

• www.navigatingcancer.com

• www.peersupportnetwork.org

• www.caringbridge.com

• www.ihadcancer.com

• www.inspire.com

• www.livestrong.com

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Breast Cancer Self-Awareness1. Know your risk:

– Talk to your family to learn about your family history

– Talk to your provider about your personal risk of breast cancer

2. Get screened:– Ask your doctor which screening tests are right for you if you are at a higher risk

– Have a mammogram every year starting at age 40 if you are at average risk

– Have a clinical breast exam every 3 years starting at age 20, and every year starting at 40

3. Know what is normal for you:See your PCP if you notice any of these breast changes:– Lump, hard knot or thickening inside the breast or underarm area

– Swelling, warmth, redness or darkening of the breast

– Change in the size or shape of the breast

– Dimpling or puckering of the skin

– Itchy, scaly sore or rash on the nipple

– Pulling in of your nipple or other parts of the breast

– Nipple discharge that starts suddenly

– New pain in one spot that doesn’t go away

4. Make healthy lifestyle choices:– Maintain a healthy weight

– Add exercise into your routine

– Limit alcohol intake

– Limit postmenopausal/birth control hormone use

– Breastfeed, if you can