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BREAST CANCER:Half a million women later…
Amy Miglani M.D
September 3, 2004
PERCEPTION VS. REALITY
46% women think they will get Breast Cancer 4% women will die from Breast Cancer
36% women will die from Heart Disease 4% women think they will get Heart Disease
STATISTICS
In 2002: 205,000 women were diagnosed with Breast Cancer & 40,000 women died from Breast Cancer
Breast Cancer is the leading cause of death in women 40-55 years
30 million mammograms done yearly; 66 million screens should be done
MAJOR RISK FACTORS
Age Family History – especially premenopausal
…think BRCA1/BRCA2 Personal History of Breast Cancer History of atypical hyperplasia on biopsy
MINOR RISK FACTORS
Early menarche Late menopause Nulliparous >35yrs at first pregnancy ??HRT…
USPSTF- SCREENING MAMMOGRAPHY
Screening mammogram with or without clinical breast exam, every one to two years for women aged 40 and older.
CLINICAL CONSIDERATIONS
Evidence is strongest for women 50-69 Between 40-49, absolute benefit is less Older than 70, screening has an unclear
effect on mortality
When to stop screening becomes a judgement call.
USPSTF- CLINICAL BREAST EXAM
Evidence is insufficient to recommend for or against clinical breast exam alone to screen for breast cancer
CLINICAL CONSIDERATIONS
Most studies included both mammography and CBE, unclear what incremental benefit CBE adds
National Breast and Cervical Cancer Early Detection Program- CBE detects 5% of cancers not visible on mammography
USPSTF-SELF BREAST EXAM
Evidence is insufficient to recommend for or against teaching or performing routine breast self-examination
AN ABNORMAL MAMMOGRAM…WHAT NEXT?
BI-RADS Categories
1: Negative
2: Benign
3: Probably Benign
4: Suspicious
5: Highly suggestive of malignancy
0: Incomplete
AN ABNORMAL MAMMOGRAM
Negative/Benign- Routine screening, no intervention
Probably Benign (3)- 6mo follow up diagnostic mammogram
Suspicious/Highly Suggestive- Clinical exam. → PALPABLE- FNA or Core Biopsy NON-PALPABLE- U/S or stereotactic guided FNA or Core Biopsy
DOCTOR, I FEEL A LUMP…WOMEN WITH PALPABLE MASSES
Breast Cancer was found in 11% of women complaining of a lump
History: Location, How long, Nipple discharge, Size change, relation to menstrual cycle
Physical: Single, Hard, Immovable, Irregular borders, >2cm
PALPABLE MASS
When the woman is <35 yrs…
1) Without evidence of malignancy, have patient return in 3-10d after next menses to see if it regresses
2) If feels cystic → FNA
Clear/Green Fluid- Reassurance and f/u in 4 weeks
Bloody Fluid- Cytology
3) If doesn’t feel cystic → Ultrasound
Solid mass- FNA, Core Needle Biopsy, or Excisional
Biopsy
PALPABLE MASS
When the woman is >35…
1) Diagnostic Mammography
Negative/Benign- Repeat clinical exam
Probably Benign- Ultrasound
Suspicous/Suggestive-F/U with surgeon for tissue sample
ULTRASONOGRAPHY
Determines whether breast mass is a simple or complex cyst or a solid tumor. It is most useful for…
-Women <35
-If a mass on screening mammo can’t be felt
-Pt declines FNA of mass
-Mass is too small or too deep for FNA
FINE NEEDLE ASPIRATION
Used to determine if a palpable lump is a simple cyst
-22-24 gauge needle
-+/- local anesthesia
-Can be therapeutic if all fluid is removed
-Clear/Green Fluid- reassure patient
-Bloody Fluid- Cytology, 7% cases are cancer
CORE NEEDLE BIOPSY
Since surrounding tissue is obtained, it is useful for distinguishing atypical hyperplasia and ductal carcinoma in situ from invasive disease.
-14-18 gauge needle
-Most often for evaluating non-palpable lumps with stereotactic or ultrasound guidance
GENETICS
Inherited alterations in genes BRCA1 and BRCA2 are involved in many cases of hereditary breast cancer.
Women with these mutations are 3-7 times more likely to develop premenopausal breast cancer than those without the mutations
WHO SHOULD BE TESTED?
In 2003, the American Society of Clinical Oncology recommended testing when
1) There is family history suggesting genetic cancer susceptibility
2) The test can be adequately interpreted3) The results will aid in the diagnosis and
management of patient/family at hereditary risk of cancer
OPTIONS IF POSITIVE
Prophylactic Mastectomy Intensive Surveillance Chemoprevention with Tamoxifen
BREAST CANCER AND HRT
Women’s Health Initiative
The risk of invasive breast cancer was significantly increased with combined hormone replacement.
HRT and a positive family history appear to be synergistic risk factors. Women with both have a RR=3.4