Breast Breast CancerCancer

DR/FATMA AL-THOUBAITYASSOCIATE PROFESSORSURGICAL CONSULTANT

Introduction.Introduction. Epidemiology.Epidemiology. Risk factor.Risk factor. Clinical features.Clinical features. Screening.Screening. BSE.BSE.

18.8%.18.8%. 30.6% less than 40 years.30.6% less than 40 years. 73.5 % locally advanced disease.73.5 % locally advanced disease.

Breast cancer :a lot to be done’’. Breast cancer :a lot to be done’’. JKAU:Med Sci,vol 7,(1999).JKAU:Med Sci,vol 7,(1999).

The most common form of cancer The most common form of cancer among women.among women.

The second most common cause of The second most common cause of cancer related mortality.cancer related mortality.

1 of 8 women (12.2%)1 of 8 women (12.2%) One third of women with breast One third of women with breast

cancer die from breast cancer.cancer die from breast cancer.

What is breast cancer?What is breast cancer? Breast cancer is where cancerous Breast cancer is where cancerous

(malignant) cells are found in the (malignant) cells are found in the breast tissue.breast tissue.

There are several types of breast There are several types of breast cancer.cancer.

Ductal cancer (effects the ducts Ductal cancer (effects the ducts and also is the most common and also is the most common type)type)

Lobular .Lobular . Inflammatory cancer.Inflammatory cancer.

Types of breast cancerTypes of breast cancer

In situIn situ Intraductal (DCIS)Intraductal (DCIS) Intralobular (LCIS)Intralobular (LCIS)

InvasiveInvasive Infiltrating ductal carcinomaInfiltrating ductal carcinoma Tubular carcinomaTubular carcinoma Medullary carcinomaMedullary carcinoma Mucinous carcinomaMucinous carcinoma

Breast Cancer-Breast Cancer-EpidemiologyEpidemiology

#1 noncutaneous cancer in U.S. women#1 noncutaneous cancer in U.S. women >200,000 cases of invasive disease in 2002>200,000 cases of invasive disease in 2002

#2 cancer death (North American women)#2 cancer death (North American women) (#1=lung cancer) (#1=lung cancer) 40,000 deaths in 200240,000 deaths in 2002

1 in 8 lifetime incidence1 in 8 lifetime incidence 1 in 30 women will die of breast cancer1 in 30 women will die of breast cancer Incidence increases with ageIncidence increases with age

Risk Factors for Risk Factors for BreastBreast Cancer Cancer

Female (1% male)Female (1% male) AgingAging Relative (mother Relative (mother

or sister)or sister) Menstrual historyMenstrual history

early on setearly on set late menopauselate menopause

Child birthChild birth After the age of 30After the age of 30

Exogenous EstrogenExogenous Estrogen Hormonal replacement Hormonal replacement

therapy(HRT)therapy(HRT) 30% increased risk 30% increased risk

with long term use with long term use Oral Contraceptives(OC)Oral Contraceptives(OC)

risk slightrisk slight risk returns to normal risk returns to normal

once the use of OC’s once the use of OC’s has been discontinuedhas been discontinued

Risk Factors for Risk Factors for BreastBreast CancerCancer

Radiation exposureRadiation exposure Breast diseaseBreast disease

Atpyical HyperplasiaAtpyical Hyperplasia Intraductal carcinoma in situIntraductal carcinoma in situ Intralobular carcinoma in situIntralobular carcinoma in situ

ObesityObesity DietDiet

FatFat AlcohoAlcoholl

GeneticsGenetics BRCA-1BRCA-1 BRCA-2BRCA-2 P53, Rb-1P53, Rb-1 Her-2/neu, c-Her-2/neu, c-

erB2, c-mycerB2, c-myc

Incidence of Breast CA Incidence of Breast CA Increases with AgeIncreases with Age

0123456789

10

Probability of

Developing Invasive Breast CA

(% )

Age 30 Age 40 Age 50 Age60

Current Patient Age

next 10 yrnext 20 yrnext 30 yr

Abnormal signs and Abnormal signs and symptomssymptoms

PuckeringPuckering DimplingDimpling RetractionRetraction Nipple dischargeNipple discharge Thickening of skin or lump or Thickening of skin or lump or

“knot”“knot” Retracted nippleRetracted nipple

Abnormal signs and Abnormal signs and symptomssymptoms

Change in breast sizeChange in breast size Pain or tendernessPain or tenderness RednessRedness Change in nipple positionChange in nipple position Scaling around nipplesScaling around nipples Sore on breast that does not Sore on breast that does not

healheal

Methods of Methods of DetectionDetection

Clinical exam by MD or Clinical exam by MD or nursenurse

MammographyMammographyMonthly breast self-exam Monthly breast self-exam

(BSE)(BSE)

Mammography-Mammography-SensitivitySensitivity

Sensitivity is 77-95% overall Sensitivity is 77-95% overall 54-58% in women < 40 54-58% in women < 40 81-94% in women > 6581-94% in women > 65

Depends on lesion size, conspicuity, tissue Depends on lesion size, conspicuity, tissue density, patient age, hormone status, image density, patient age, hormone status, image quality, and interpretive skill of the radiologistquality, and interpretive skill of the radiologist

There is inter- and intra-observer variability in There is inter- and intra-observer variability in the interpretation by the radiologistthe interpretation by the radiologist

MammogramsMammograms Getting a mammogram is an Getting a mammogram is an

effective way to detect breast effective way to detect breast cancer in its early stages.cancer in its early stages.

It is recommended by the It is recommended by the AMERICAN CANCER SOCIETY AMERICAN CANCER SOCIETY that all women over 40 get a that all women over 40 get a yearly mammogram. yearly mammogram.

Its also recommended that Its also recommended that women over 20 should get a women over 20 should get a mammogram every 2-5 years mammogram every 2-5 years depending on your risk.depending on your risk.

(picture courtesy of breast cancer.org)(picture courtesy of breast cancer.org)

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Mammography Mammography

Why don’t women get Why don’t women get MXR’s?MXR’s?

Factors that may discourage annual mammography among low-Factors that may discourage annual mammography among low-income women with access to free mammograms: a study using income women with access to free mammograms: a study using multi-ethnic, multiracial focus groups. Bobo JK, multi-ethnic, multiracial focus groups. Bobo JK, Psychol. RepPsychol. Rep. . Oct. 1999, 85(2).Oct. 1999, 85(2).

Fear of radiation, anxiety that may not find Fear of radiation, anxiety that may not find CA, worry that CA might actually be detected, CA, worry that CA might actually be detected, embarrassment, discomfort, painembarrassment, discomfort, pain

Factors assoc. w/ higher rates: Factors assoc. w/ higher rates: higher income, ages 65-74, non-white raceshigher income, ages 65-74, non-white races Also higher in women who obtain regular Also higher in women who obtain regular

check ups or who are vitamin userscheck ups or who are vitamin users

Clinical examinationClinical examination Performed by doctor or Performed by doctor or

trained nurse practitionertrained nurse practitioner Annually for women over Annually for women over

4040 At least every 3 years for At least every 3 years for

women between 20 and 40women between 20 and 40 More frequent examination More frequent examination

for high risk patientsfor high risk patients

Clinical Breast Exam Clinical Breast Exam (CBE)(CBE)

Sensitivity is 40-69%Sensitivity is 40-69%

Specificity is 86-99%Specificity is 86-99%

PPV is 4-50%PPV is 4-50% In one study, only 4% of women with an In one study, only 4% of women with an

abnormal CBE had cancerabnormal CBE had cancer

Staging of Breast CancerStaging of Breast Cancer

The American Joint Committee The American Joint Committee on Cancer (AJCC) has designated on Cancer (AJCC) has designated staging by TNMstaging by TNM

T= tumor sizeT= tumor size N = lymph node involvementN = lymph node involvement M = metastasisM = metastasis

Monthly Self ExamsMonthly Self Exams Its important to remember Its important to remember

that monthly self exams are that monthly self exams are also a good tool for early also a good tool for early detection.detection.

Hereis a web site that has the Hereis a web site that has the complete monthly self-exam complete monthly self-exam program @program @

.cyberus.ca/bse2.htm#bse2 http://www.infobreastcancer

Picture courtesy of Yahoo healthPicture courtesy of Yahoo health

Breast Self Exam (BSE)Breast Self Exam (BSE)

Accuracy of BSE is unknownAccuracy of BSE is unknown

Estimate of sensitivity: 26-41%Estimate of sensitivity: 26-41%

Specificity is unknownSpecificity is unknown

Breast Self Breast Self ExaminationExamination

Opportunity for woman Opportunity for woman to become familiar to become familiar with her breastswith her breasts

Monthly exam of the Monthly exam of the breasts and underarm breasts and underarm areaarea

May discover any May discover any changes earlychanges early

Begin at age 20, Begin at age 20, continue monthlycontinue monthly

When to do BSEWhen to do BSE Menstruating women- 5 to 7 Menstruating women- 5 to 7

days after the beginning of days after the beginning of their periodtheir period Menopausal women - Menopausal women - same date each monthsame date each month Pregnant women – Pregnant women – same date each monthsame date each month Takes about 20 minutesTakes about 20 minutes Perform BSE at least Perform BSE at least once a monthonce a month Examine all breast tissueExamine all breast tissue

Why don’t more Why don’t more women practice BSE?women practice BSE?

FearFear EmbarrassmentEmbarrassment YouthYouth Lack of Lack of

knowledgeknowledge Too busy, Too busy,

forgetfulnessforgetfulness

Reference Reference

httpbcra.nci.nih.gov/brc/ Clinical surgery edited by Michael Clinical surgery edited by Michael

M.Henry Jeremy M.Henry Jeremy N.Thompson.second edition.N.Thompson.second edition.