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Breast Cancer Update

Breast Cancer Update. Miss B.N. Shah Consultant Surgeon Ealing Hospital. Current Incidence of breast cancer. Common disease 8% risk of development up to 74y Varies between countries Rare <20y 25 per 100,000 from 30-34y 200 per 100,000 from 45-50y 463 per 100,000 from 70-79y .

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Breast Cancer Update

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  1. Breast Cancer Update Miss B.N. Shah Consultant Surgeon Ealing Hospital

  2. Current Incidence of breast cancer • Common disease • 8% risk of development up to 74y • Varies between countries • Rare <20y • 25 per 100,000 from 30-34y • 200 per 100,000 from 45-50y • 463 per 100,000 from 70-79y

  3. Incidence by race

  4. Bad news • Commonest cause of death in women aged 40-50y • Second commonest cause of death from cancer in women overall • Only 20-50% at most, related to attributable risk

  5. Good news • Breast cancer mortality has fallen both in the UK and USA for the past decade • 56% 5 year relative survival (1968-72) • 70% 5 year relative survival (1988-92)

  6. Mortality

  7. anatomy

  8. Lobule of the breast

  9. Epidemiology

  10. Influence of oral contraception (1) • Weakly associated with breast cancer risk • Single study evaluated effect on women with F.H • Cohort –showed R.R 3.3 among sisters and daughters of probands • Risk most evident before and during 1975

  11. Influence of oral contraception (2) • Population based studies don’t show this effect • Estimated excess number of cancers between starting use and 10 years after stopping 0.5-5% • No hard evidence of increased risk of having breast cancer diagnosed 10y or more after stopping

  12. Influence of HRT (1) • Data more extensive , variable, many confounding issues • No long term RCT’s • Collaborative group on Hormonal Factors in Breast Cancer • Meta-analysis of 90% of world data • 54,000 women, 33% had used HRT for 5 y or more

  13. Influence of HRT (2) Two main consistent findings • The length of time on HRT was related to extra breast cancers in users • This increased risk disappears within 5y of stopping • Women who use HRT for a short time around the menopause have a very low excess risk

  14. Influence of HRT…..nitty, gritty Cumulative incidence for women aged 50-70y is 45 per 1,000 in ‘never users’ • 2 per 1,000 extra cancers after 5yrs on HRT • 6 per 1,000 extra cancers after 10yrs • 12 per 1,000 extra cancers after 15yrs

  15. HRT…what to do? • RCTs in UK, Italy, Scandinavia and Canada • Each patient treated on their own merit • Apply the principle of ‘ treatment tailored strategies’

  16. Genes and hereditary factors (1) • Susceptibility genes responsible for only 5-10% of breast cancers • great strides in characterising genes responsible • Almost nothing known about various gene interactions +/- environmental factors

  17. Genes and hereditary factors (2) • 1990 BRCA1 (17q) responsible for 90% of cases with autosomal dominant transmission of breast cancer and ovarian cancer 45% in breast cancer alone • BRCA2 (13q)

  18. Genes and hereditary factors (3) Hereditary breast cancer • Onset <45y • excess bilateral cancer • Multiple primary cancer • 80% BRCA1, 20% BRCA2 • Ashkenazi 1:100 risk of breast /ovarian/both • Screening useful

  19. Genes and hereditary factors Familial breast cancer • Positive FH • 1 or more 1st or 2nd degree relatives that do not fit the HBCa category • Risk ratios increase with the number of affected relatives • Quantitative risk assessment helpful • Genetic testing not yet feasible

  20. Genes and hereditary factors (3) Multiple cancer syndromes • Li-Fraumeni syndrome (p53 mutation) • Cowden ‘s disease (mutation of PTEN gene) • Ataxia Telangectasia (11q)

  21. The future • Rapid progress – clinical and molecular genetics • find ways to cost DNA testing • ?legislaton to prohibit discrimination ‘genetic labelling’- employers,insurance companies etc.

  22. GP practice • The Department of Health point out that a GP with a list of 2000 patients is likely to see only one woman a year who has breast cancer. But they will see a lot more women who have non-cancerous breast conditions such as • Cysts - sacs of fluid in the breast tissue and most common in the 40-60 year age group • Fibroadenomas – a collection of fibrous glandular tissue and most common in 20-30 year age group • Diffuse nodularity – ‘lumpy’ breasts, which are common in all age groups up to the age of 50 • Breast pain – this is not a common symptom of breast cancer • Although 9 out of 10 breast lumps are not cancer, the Department of Health recommends that any woman over 30 who has a lump in the breast that does not go away should be examined by her GP. 

  23. Early referral • A distinct lump in women under 30 • ‘Lumpy’ breasts that do not go away after a period has finished • A sore infected area on the breast (abscess) • Recurrent cysts • Breast pain that does not go away with reassurance, painkillers prescribed by your GP and wearing a well supporting bra • Any type of nipple discharge in women over 50 • Any woman under 50 who has a blood stained discharge or a discharge from both nipples that is enough to stain clothing

  24. Guidelines for Urgent Referral • The symptoms that need urgent referral in 2 weeks for possible cancer of the breast are • An area skin on the breast that is inflamed and sore (ulcerated) • Small lumps that appear just under the skin nodules - these are often shiny and red • Dimpling or distortion of the skin, called peau d'orange • A rash on a nipple or surrounding area called nipple eczema • Nipples that have turned in (inverted) within the past 3 months

  25. Imaging • Ultrasound (U) • Mammagram (M) 1- normal 2 - benign 3 - probably benign 4 - probably malignant 5 - malignant

  26. Cytology C1 - inadequate sample C2 - definitely benign C3 - probably benign C4 - probably malignant C5 - malignant

  27. Core Biopsy B1 - normal B2 - benign B3 - probably benign B4 - probably malignant B5 - malignant

  28. Management of a lump

  29. Management of a lump

  30. Management of a lump

  31. Management of a lump

  32. Management of a lump

  33. Lymphatic drainage

  34. Management of the axilla Clearance Levels,1, 2, 3 Sample 4 nodes Sentinel node 50:50 divide

  35. Sentinel Node axillary dissection • Guided localisation • minimally invasive alternative to traditional axillary dissection • Blue dye • Radioisotope • <5% false negative • The future

  36. Screening (U.K.) • Two view • Double reading • 50-65years • 3 yearly

  37. UK Trial of early detection of breast cancer • 1999 • 27% decreased breast cancer mortality • 45 – 60years • Supports Edinburgh trial (21%)

  38. Anatomy

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