BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS

1. BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS DR. A. AKHATOR FWACS, FICS SENIOR LECTURER DELSU CONSULTANT SURGEON DELSUTH

2. PRE-TEST • Breast cancer is the most common cancer in women in Nigeria • Breast cancer is the most common cause of cancer related deaths • Breast cancer commonly present as painful breast lump • Prognosis of breast cancer is related to the size of the breast tumor • Trastuzumab (HerceptinR) is treatment for ER/PR positive tumor

3. LEARNING OBJECTIVES • Realize the burden of breast cancer in our environment • The importance of early diagnosis in management of breast cancer • Evaluate breast cancer symptoms and recommend appropriate management

4. OCTOBER IS BREAST CANCER AWARENESS MONTH

5. BREAST

7. INTRODUCTION • Breast cancer – malignant neoplasm arising in the breast. • Most common cancer in women worldwide. • Incidence in Nigeria is 33/100,000 • Incidence in males 1-9% of cases • Peak age 42 years • 78% locally advanced disease • 22% metastatic disease

8. THE FACTS ABOUT BREAST CANCER • APPROXIMATELY EVERY 3 MINUTES A WOMAN IS DIAGNOSED WITH BREAST CANCER • APPROXIMATELY EVERY 12 MINUTES A WOMAN DIES FROM BREAST CANCER • INCIDENCE INCREASING 5%/YEAR IN DEVELOPING COUNTRIES • A REVIEW 1991 – 33% ADVANCED DISEASE IN DEVELOPED COUNTRIES • 2007 – 60-80% ADVANCED DISEASE IN DEVELOPING COUNTRIES

9. MORE FACTS • IN THE UK 2009 • NEW CASES - 38,212 FEMALES, 250 MALES • SECOND COMMONEST CANCER DEATHS • IN US • 211, 240 NEW CASES EXPECTED IN WOMEN • 1,690 NEW CASES IN MEN • African-American women have a lower incidence but higher mortality • They also have higher risk for triple-negative tumours • INCIDENCE – 128.6/100,000 POPULATION • Life time risk of 1 in 8 women

10. Factors that increase risk • Family History • Lifestyle • Personal History

11. Family History • Mother, sister, or daughter has developed breast cancer before menopause 3 x. • If two or more close relatives (e.g., cousins, aunts, grandmothers) have/had breast cancer. • Mutations in genes BRCA1 and BRCA2 increase one's susceptibility to breast cancer.

12. FAMILY HISTORY • SHARED GENETIC MAKEUP • SHARED LIFESTYLE • SIMILAR ENVIRONMENTAL EXPOSURE • 5-10% CAUSED BY INHERITED GENETICS

13. PERSONAL HISTORY • Previous history of breast cancer • Previous history of benign breast disease • Menarche <12 years • Hormonal contraceptives – current and recent users • Nullipara • First delivery after 30 years • Menopause at 55 years or older • Hormonal Replacement Therapy

14. Lifestyle • Several studies found a lower incidence of breast cancer among women who exercise regularly • Higher proportion of breast cancer among obese women. • Smoking

15. OTHER LIFESTYLE FACTORS • ALCOHOL – one or more drinks a day increases risk • DIET – High in fruits and vegetables decreases risk • EXERCISE – Regular exercise decreases risk • WEIGHT – Maintaining healthy weight decreases risk

16. ENVIRONMENTAL RISK • POLYCYCLIC AROMATIC HYDROCARBONS – Chemicals produced when coal, oil, gas, garbage are burnt – increases risk • SMOKING – Passive smoking increases risk; when smoking started as teenager • ELECTROMAGNETIC FIELD – NO RISK

17. BREAST CANCER MYTHS • SHAMPOO – NOT TRUE • WEARING BRA – NOT TRUE • PUTTING MONEY IN BRA – NOT TRUE • RADIATION FROM CELL PHONES – NOT TRUE • ANTIPERSPERANTS/DEODORANTS – NOT TRUE • BREASTFEEDING GRANDCHILDREN – NOT TRUE • WITCHES INFLICT – NOT TRUE

18. CLASSIFICATION • Heterogeneous disease at each stage • Early breast cancer (Tis-2/N0-1) • In situ disease • Invasive • Late breast cancer (T3,4/N2/M1) • Locally advanced • Metastatic disease

19. STAGE GROUPING • STAGE 0 – Tis, N0,M0 • STAGE IA – T1, N0,M0 • STAGE 1B – T0 or T1, N1mi, M0 • STAGE IIA – T0 or T1, N1, M0; T2,N0,M0 • STAGE IIB – T2, N1, M0; T3, N0, M0 • STAGE IIIA – T0 to T2, N2, M0; T3, N1 orN2,M0 • STAGE IIIB – T4,N0-N2,M0; • STAGE IIIC – any T, N3, M0 • STAGE IV – any T, any N, M1

21. EARLY DIAGNOSIS ….. • Early diagnosis leads to better prognosis • The size of the tumor and extend of spread determines the prognosis • Early stage • Better possibility for cure • Less morbidity • Less toxic treatment

22. PROGNOSIS • Overall survival/Disease free interval • Quality of life • Adverse effect/toxicity of treatment • Body habitus • Psychological

23. PROGNOSTIC FACTORS • Age • Tumor size • Axillary LN status • Histological grade • Receptor status – ER, PR • HER2-neu(C-erb B2)

24. OVERALL SURVIVAL • CURE RATES FOR BREAST CANCER • 5 year cure rates of >90% obtainable for early tumours, • < 30% for late tumours

25. SURVIVAL RATES BY STAGE • Stage 0 – 93% • Stage I – 88% • Stage IIA – 81% • Stage IIB – 74% • Stage IIIA – 67% • Stage IIIB – 41% • Stage IIIC – 49% • Stage IV – 15%

26. QUALITY OF LIFE • Scars of treatment/no breast • Younger survivors face • Emotional stresses • Trouble with social functioning • Chemotherapy induced early menopause • Sexual difficulties

27. DIAGNOSIS • ASYMPTOMATIC PATIENT • SCREENING • BSE • CBE • Mammography • MRI • SYMPTOMATIC PATIENT • Clinical evaluation • Diagnostic investigations

28. Breast Self Exam Be Safe, Be Sure

29. Advantages of BSE • It is simple and easy to perform. • It is convenient and requires little time. • It is private. • It involves no medical cost • It is safe and non-invasive. • It requires no specific equipment.

30. Methods of training • Pamphlets and leaflets. • Instructional videos. • Demonstrations and personal instructions.

31. Breast-self-examination • Breast self examination – monthly • Understand the breast and look for changes • Development of a lump. • Swelling. • Skin irritation or dimpling. • Nipple pain or retraction. • Redness or scaliness of the nipple or breast skin. • Discharge - other than milk. • Standing and lying

32. When to do a Breast Self-Exam The best time to do breast self-exam is right after her period, when breasts are not tender or swollen. If she does not have regular periods or sometimes skip a month, do it on the same day every month.

33. Clinical Breast Examination • BREAST EXAM BY DOCTOR (CBE) – EVERY 3 YRS BETWEEN 20-39YRS; • YEARLY AFTER 40YRS, before mammogram • POOR SENSITIVITY - 54% • HIGH SPECIFITY – 94% • CBE-detected tumourshas 70% survival

34. Mammogram • XRAY OF THE BREAST (MAMMOGRAM) – YEARLY AFTER 40 YRS • Mammography-detected tumours has 90% survival • Mammography increased detection of DCIS from 1% to 21% • Regular screening by mammography and CBE decrease mortality by 25 – 30% in women 50years or older

35. EARLY DIAGNOSIS • TRIPLE ASSESSMENT • CLINICAL EVALUATION • IMAGING • HISTOCYTOLOGY

36. CLINICAL EVALUATION • History • Progression of symptoms • Risk factors for breast cancer • Treatment to date • Physical examination • Local • systemic

37. FEATURES OF BREAST CANCER • Breast lumps – painless • Swelling of the breast • Nipple discharge – blood stained • Retraction of the nipple • Changes in the skin of the breast • Breast or nipple pain • Signs of spread

38. LUMP IN THE BREAST

40. LUMP IN THE AXILLA

42. RETRACTED NIPPLE

43. RETRACTED NIPPLE

44. INFLAMMATORY BREAST CANCER

45. BLOODY NIPPLE DISCHARGE

46. BREAST ULCER

47. BREAST ULCER

48. Breast cancer in a man

49. IMAGING • Breast scan • Mammogram • Digital mammogram • Computer aided diagnosis (CAD) • MRI • OTHERS • Thermography • Scintimammography • Tomosynthesis (3D Mammography)

50. HISTOCYTOLOGY • TYPES OF BIOPSY TECHNIQUE • FNAC • Core Needle • Vacuum assisted • Open biopsy • Incisional • excisional