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RECENT DEVELOPMENTS IN TREATMENT OF BREAST CANCER

RECENT DEVELOPMENTS IN TREATMENT OF BREAST CANCER. BY DR.DILIP MURARKA MS, MCF (USA) Consulting Surgeon / Surgical Oncologist. Parts of the Breast. Breast (Sagittal View). BREAST CANCER Statistics.

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RECENT DEVELOPMENTS IN TREATMENT OF BREAST CANCER

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  1. RECENT DEVELOPMENTS IN TREATMENT OF BREAST CANCER BY DR.DILIP MURARKA MS, MCF (USA) Consulting Surgeon / Surgical Oncologist

  2. Parts of the Breast

  3. Breast (Sagittal View)

  4. BREAST CANCER Statistics Mortality all over the world 400,000 annually Mortality in U.S.A. 43,000 annually Incidence in U.S.A. 1,80,000 in women 1,000 in men Age adjusted incidence U.S.A. [White] U.S.A. [Black] Mumbai 1983 study 104.2/100,000 87/100,000 20.5/100,000 Bombay cancer registry [1987] Parsee Hindu Muslim Christian 47.2% 22.8% 25.7% 26.2%-

  5. BREAST CANCER SCENARIO The incidence of breast cancer is rising in every country of the world especially in developing countries such as India. • Incidence Incidence is rising in India 1 in 28 women (urban areas) 1 in 80 women (rural areas) It is more prevalent in the higher socio-economic groups. Roughly 100000 new cases annually approx 3% increase per year Tata Hosp - Registered new cases annually - 2000 Early breast cancer 55% Locally advanced 35%

  6. SIGNS • No Classic Signs • Certain specific signs -Peau d’orange -Inflammatory Ca Breast -Paget’s disease

  7. RISK FACTORS FOR BREAST CANCER • Female sex • Age • Parity • Family history • Genetic factor Intermediate risk factors • Early menarche, Late menopause • Exposure to radiation • Oral Contraceptives • Smoking / Alcoholism / High fat diet • Atypia /Hyperplasia • Women on HRT

  8. Groups • Operable Breast Cancer T < 5 cm, N0 or N1, Mo • Large Operable Breast Cancer T > 5 cm, N0 or N1, M0 • Locally Advanced Breast Cancer • Metastatic Breast Cancer

  9. Early Stages of Breast Cancer - Stage 0

  10. Early Stages of Breast Cancer - Stage 1

  11. Early Stages of Breast Cancer - Stage 2

  12. Advanced Stages of Breast Cancer - Stage 3

  13. Advanced Stages of Breast Cancer - Stage 4

  14. Locally Advanced Breast Cancer • Skin involvement : oedema, ulceration, infiltration, satellite nodules • Axillary Nodes : Matted / Fixed • SC/IMC (Ipsilateral) • Chest wall fixity • Arm Oedema

  15. Operable Breast Cancer • T/N Staging (Clinical) • Histology (FNAC / Incision Bx) • Bilateral Film Mammogram (for BCT) • Eg/PgR (for NACT) • Routine Pre Anesthetic Work up • Metastatic Work up Not Recommended (< 2 %) STRONG CLINICAL SUSPICION – OVERRULE NEGATIVE FNAC / MAMMOGRAPHY FOR EXCISION Bx

  16. Operable Breast Cancer Surgical Options : • Breast Conservative Therapy (BCT) Wide Excision with Complete Axillary Clearance • Modified Radical Mastectomy (MRM)

  17. Lumpectomy Lumpectomy Is the removal of the breast cancer and a portion of normal tissue around the breast cancer lump (the areas removed during the surgery are shaded in green).

  18. Lumpectomy

  19. Simple Mastectomy Total (or simple) mastectomy During a total (or simple) mastectomy, the surgeon removes the entire breast (including the nipple, the areola, and most of the overlying skin) and may also remove some of the lymph nodes under the arm

  20. Simple Mastectomy

  21. Modified Radical Mastectomy

  22. Modified Radical Mastectomy Radical mastectomy During a radical mastectomy, the surgeon removes the entire breast (including the nipple, the areola, and the overlying skin), the lymph nodes under the arm

  23. Quadrantectomy (Partial Mastectomy)

  24. Quadrantectomy (Partial Mastectomy) Partial (segmental) mastectomy Involves the removal of the breast cancer and a larger portion of the normal breast tissue around the breast cancer (the areas removed during the surgery are shaded in green).

  25. Showing Upper Flap Showing a specimen of Lumpectomy

  26. After MRM Showing Upper & Lower Flap

  27. Final Scar Operated Specimen

  28. Operable Breast Cancer Contraindications to BCT : • Multicentric disease (> 1 quadrant) • Extensive microcalcification on Mammogram • Doubtful Compliance with RT • Pregnancy (1st / 2nd Trimester and Precious child • Cosmesis unsatisfactory

  29. Models Histopathology Report • Tumour Size (3 D), Type, Grade (MRB Score) • Presence of Extensive Intraductal Carcinoma (EIC) • Lymphovascular Embolisation • Cut Margin Status • No of Nodes +ve / Total No. of Axillary Nodes • Receptor Status : ER and PgR

  30. Adjuvant Therapy • Systemic : Hormone therapy and/or Polychemotherapy All women with N+ and/or ≥ 1 cm tumour ER or PgR +ve ER & PgR –ve Premenopausal Chemotherapy + Chemotherapy Hormonal therapy only Post menopausal Hormonal therapy Hormonal therapy +/- Chemotherapy + Chemotherapy B. Low Regional : Radiotherapy All women with BCT All women with MRM with T > 5 cm, > 3 +ve nodes

  31. Locally Advanced Breast Cancer • Core / Incisional Bx for diagnosis / receptor study • Mammo Sonography – Document tumour size • Metastatic workup – X-Ray Chest, USG Abdomen, LFT, Bone Scan • Treatment Sequence – NACT – Surgery – Adj. CT – RT (Plus Tain If ERHC)

  32. Locally Advanced Breast Cancer Surgical Options : • Clinical / mammography CR  Index quadrantectomy with axillary clearance (BCT) • PR (residual disease)  a) BCT when feasible b) Simple mastectomy with axillary clearance (SMAC) • SD or PD  SMAC with or without reconstruction for skin cover • PD and Inoperable  Preop RT  Reasses for Surgery

  33. Follow Up After Primary Treatment • PE every 3 months x 2 years, biannually x 3 years, then yearly • Mammography – Annually • No other investigation in Asymptomatic patients Not cost effective, Does not prolong survival, Psychological harm

  34. Follow Up After Primary Treatment Clinical recurrence or Symptoms s/o metastases : • X-ray Chest • USG Abdomen • LFT • Bone Scan • Skeletal Survey (Suspicious / weight bearing areas) • CT / MRI as indicated

  35. Breast Cancer Screening • Periodic mammographic screening : 30 % Reduction in mortality in women > 50 years No convincing evidence of benefit in women < 50 years • Not sustainable in developing countries • Physical Examination (PE) of breast by trained personnel Sensitivity 75 %, Specificity > 90 % ; ?? Alternative to Mammography 4) Breast Self Examination (BSE) may identify interval cancers early ; No survival benefit

  36. Family History of Breast Cancer • Confers 2-3 fold increased risk of developing breast cancer • 5-10 % of such women have an over 50 fold risk • Related to mutations in BRCA 1 and BRCA 2 genes • First degree blood relatives may be tested if these mutations confirmed in the index cases • Negative Genetic testing does not eliminate risk • Positive test cannot be remedied or prevented from being transmitted vertically Genetic testing provides information in a research setting but use in routine practice needs evaluation, social debate and counselling

  37. EBM Guidelines • Breast conservation therapy is the gold standard for Early Breast Cancer provided negative resection margins are achieved and an acceptable cosmetic result can be obtained • Modified Radical Mastectomy remains the standard of treatment when disease is multicentric or compliance to postoperative radiotherapy is doubtful

  38. EBM Guidelines • Adjuvant Chemotherapy reduces death due to breast cancer by 25 % (RR) in premenopausal women Effect is halved in postmenopausal women • Adjuvant Tamoxifen reduces death in hormone sensitive breast cancer by 26 % (RR) irrespective of menopausal status

  39. EBM Guidelines • Intensive investigations are not recommended to detect metastases during routine follow up of women after completion of primary treatment • Investigate only when symptomatic

  40. EBM Guidelines • Screening Mammography alone is effective in saving lives in Post Menopausal Women • Physical examination “as effective” – one randomized trial • Premenopausal Women – Screening by Mammography and/or PE is debatable

  41. Recommended Screening Tests for Women By Age Groups (NCI)

  42. Ultrasound Mammography Needle (core) biopsy

  43. Management of Metastatic Breast Cancer • Main goal is palliation • Hormone therapy (Based on ER-PR status) • Tomaxifen 20 mg / Letrozole (2.5 mg) • Oophrectomy – premenopausal ER-PR + second line treatment • Chemotherapy – ER-PR –ve CAF, CMF, CEF paclitaxel • Radiotherapy – Bone metastases – pain relief – neurological & skeletons. Complication of bone mets. Brain Metastasis :- Relieving / Preventing neurological manifestation single & multiple

  44. Frequently Asked Questions (FAQ’s) • Is everything in breast malignant ? • Is there any non surgical Rx to breast malignancy ? • What is hormone or chemotherapy ? • When do they begin ? • Are there any side effects with chemotherapy ? • What are the advices given to the patient who is an chemotherapy by the doctor ?

  45. Frequently Asked Questions (FAQ’s) • Will there be any disturbances in the menstrual cycle ? • Is hair loss permanent or not ? • Will my breast be removed due to breast malignancy ? • Are there any cosmetic procedure available after breast Sx ? • What is radiation therapy and what are its side side effect ?

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