BREAST DISEASES AUGUST 2013

Joel A. Okoli, MD, MPH, FACSAssociate Professor of SurgeryDivision of Surgical Oncology

Morehouse School of MedicineAtlanta, GA

OBJECTIVES

1. Understand the epidemiology of breast cancer2. Know the screening and diagnostic modalities3. Discuss the common benign breast diseases4. Know the therapeutic approach to non-invasive and

invasive breast cancers

Question 1

• The following statements are true about breast cancer in the US EXCEPT:

• A. Breast cancer is the leading cause of cancer mortality in women• B. The mortality rate for breast cancer has been decreasing for the past

several years• C. Stage for stage the prognosis for male breast cancer is similar to female

breast cancer• D. Over 70% of women diagnosed with breast cancer have no family

history• E. Breast cancer is a very heterogeneous disease, hence treatment must

be individualized

Epidemiology of breast cancer

• 2012: 229,060 new cases• Females: 226,870 new cases• most common female cancer—30% • F: 39,510 deaths, 2nd only to lung ca

• Males: 2,190 new cases; 410 deaths•

AGE•Birth - 39: 1 in 207•40-59: 1 in 24•60-79: 1 in 13•Birth to death: 1 in 7• Jemal et al:CA Cancer J Clin 2005 55: 10-30 •2% of breast ca <30; 70% Dx’d > 50• Kearny& August: ACoS Breast Disease• Curriculum, 2003•NO AGE GROUP IN WHICH THE PROBABILITY OF HAVING BREST CA IS ZERO

•

Question 2

• The following statements about breast cancer epidemiology are false EXCEPT:

• A. The most important risk factor for breast cancer is increasing age• B. From birth to age 39, the probability of getting breast cancer is 1 in

1000• C. Using risk estimation models, it is possible to determine the risk of

breast cancer and thus determine the use of chemoprevention• D. The incidence and mortality rates for African-Americans are higher than

for Caucasians• E. Having the first child before the age of 30 decreases the risk of having

any type of breast cancer

Risk Estimation Models-Gail•Based on age, menarche, age at 1st life• birth, previous biopsies, atypical hyperplasia, • breast ca in 1o relatives•Provides 5-yr and life time (to age 90) risk• estimate•If for example, 5-yr risk > 1.66%, consider• chemoprevention•Overestimates risk in women not screened• regularly•Not useful in pts with prior breast ca ,DCIS or LCIS•Not applicable if family history suggests HBC Kearny & August: ACoS Breast Disease Curriculum, 2003

Proven Risk Factors

•Gender F:M- -100:1•Age•Family history•High risk lesions(ADH, ALH, LCIS)•Early menarche, late menopause•Nulliparity or first birth after age 30•Radiation exposure•HRT•Alcohol consumption

Risk Estimation Models-Claus

•Includes information about :No. of breast ca.Age at onsetPaternal and maternal relatives•Useful for women with a strong family hx of breast ca with unknown• BRCA1 and BRCA2 status Kearny & August: ACoS Breast Disease Curriculum, 2003

Question 3

• The following statements regarding screening for breast cancer are true EXCEPT:

• A. Mammogram is very sensitive so if it is negative, clinical breast examination is unnecessary

• B. Ultrasonography is NOT a useful screening modality.• C. While MRI is more sensitive than MGM, it is only recommended for

high risk populations when MGM is non diagnostic or as an adjunct to MGM in select cases

• D. A lady whose mother had breast cancer at age 40 should have her baseline MGM at age 30

• E. BSE while considered optional by American Cancer Society may sometimes be useful

ACS Breast Ca Screening Guidelines

•Age 20-39 CBE; monthly BSE (optional); MGM >25 if risk is increased•Age > 40Annual MGM, CBE; monthly BSE (optional)•MGM and CBE are complementary as 10-15% of breast cancers are only detected by CBE• CA Cancer J Clin 2009; 59:27-41 (Jan/Feb 2009)

Screening in High Risk Populations Annual Screening MGM & MRI beginning at age 30 for: Evidence Based-- known BRCA carriers 1st degree relative of BRCA carrier (untested) > 20-25% lifetime risk Expert Consensus Opinion— Radiation to chest between age 10 and 30 years Li-Fraumeni syndrome and first-degree relatives Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree relatives Saslow, Boetes, Burke et al: CA Cancer J Clin 2007; 57:75-89

Screening MRI: Insufficient Evidence for or against

• Lifetime risk 15–20%, as defined by BRCAPRO • Lobular carcinoma in situ (LCIS),atypical lobular

hyperplasia (ALH), atypical ductal hyperplasia (ADH)• Heterogeneously or extremely dense breast on

mammography Saslow, Boetes, Burke et al: CA Cancer J Clin 2007; 57:75-89

Question 4

• The following statements about hereditary breast cancers are true EXCEPT:

A. constitute 5-10% of all breast ca.• B. Multiple generations• C. Multiple 1o relativesD. Both males and females are equally affectedE. When suspected consultation with a genetic counsellor is

useful

Effect of Screening on Mortality from Breast Ca

•In the US, 1975-2000: total reduction in• mortality rate using 7 statistical models- -• 28 to 65% (median, 46%).•By 2000, approx. 70% of women >40• had MGM in the previous 2 yrs. Berry et al: NEJM 2005;353: 1784-1792

Findings Suggestive of Hereditary Breast Cancer (HBC)

• HBCs constitute 5-10% of all breast ca.• Multiple generations• Multiple 1o relatives• Premenopausal breast ca• Bilateral breast ca• Family h/o ovarian ca• Family h/o other cancers Kearny & August: ACoS Breast Disease Curriculum, 2003

Question 5

• Genes associated with HBC include the following EXCEPT:

A. BRCA 1 & 2 B. P53C. CD 1D. Possibly ATME. MSH2

Copyright ©2005 American Cancer Society

From Chen, Y.-C. et al. CA Cancer J Clin 2005;55:45-54.

FIGURE 2 Proportion of Breast Cancer Attributable to Known and Unknown Germline Genetic Mutations

Genes Associated with HBC

•BRCA1•BRCA2•P53 (Li-Fraumeni syndrome)•CD1 (Cowden Syndrome)•Possibly ATM (Ataxia Telangiectasia Mutated)

BRCA1 & BRCA2 Genes•BRCA1Chromosome 17q2140-50% of HBC50-85% risk of female breast ca2nd breast cancer risk up to 65%Ovarian ca - -20-40%Male breast cancer-up to approx. 6%Probable increased risk of prostate caPossible increased risk of colon ca Wonderlick: Lynn Sage Breast Cancer Program, Northwestern CCC Cancer and Genetics

•BRCA2Chromosome 13q1233-50%of HBC50-85% risk of female breast ca2nd breast cancer risk 50%Ovarian ca- -10-20%Male breast ca- - 6%Increased risk of prostate caPossible increased risk of colon ca Wonderlick: Lynn Sage Breast Cancer Program, Northwestern CCC

Cancer and Genetics

HBC Management

•Monthly BSE starting at age 18 y•CBE, semiannually, starting at age 25•Annual MGM and breast MRI screening starting at age 25, or individualized based on earliest age of onset in family•Discuss option of risk reducing mastectomy on case-by-case • basis and counsel regarding degree of protection, reconstruction• options

•Consider chemoprevention, discussing risks and benefits•Advise about risk to relatives, genetic counseling and possible testing• for at-risk relatives•Education regarding signs and sxs of cancer(s) esp. those associated• with BRCA gene mutations• NCCN Practice Guidelines-v.1.2006

Breast Evaluation

•The ultimate goal is to classify findings as:Normal Clearly benignPossibly malignant Not always readily apparent hence, consultation is necessary

Question 6

• During a modified mastectomy and axillary dissection, which of the following nerves, if divided, produces the least significant morbidity?

• A. Long thoracic nerve (respiratory nerve of Bell).• B. Intercostobrachial nerve.• C. Lateral pectoral nerve.• D. Axillary nerve.• E. Thoracodorsal nerve.

• 4 types of mastectomy• Modified radical mastectomy – key difference is

pec major or NAH• Radical mastectomy – entire breast is removed

with pec major, and axillary lymph node dissection (level 1, 2, sometimes 3)

• Partial mastectomy• Simple/total mastectomy – superior – clavicle

sternum, intermammary border; lateral border of pectoralis major

• Pec minor NOTHING to do with it

Breast Evaluation

NON-HEALING NIPPLE ULCER

Question 7

• The following statements about breast cancer evaluation are true EXCEPT:

A. Mammography can miss up to 10-15% of breast cancersB. FNAB and needle core biopsy provide identical resultsC. US bx is not useful for evaluation of microcalcificationsD. Stereotactic core bx is the modality of choice for evaluation

of suspicious microcalcificationsE. Wire localized excision is reserved for pts that are not

amenable for stereotactic core bx or those for definitive surgical therapy of nonpalpable cancer

Screening Mammogram

•Asymptomatic pts•Craniocaudal(CC) and Medial-lateral• oblique (MLO)•Previous images essential •If screening is abnormal or inconclusive• additional diagnostic imaging (special views• and US) may be necessary

MICROCALCIFICATIONS

Question 8

A 41yoF had a screening MGM with equivocal finding and reported as BIRADS 0; her next recommended action includes any of the following EXCEPT:A. Do nothing else as BIRADS 0 means she has nothing wrong

with her breastB. Bring any previous MGMs for comparison with current oneC. Return for additional imaging for better definition of the

equivocal findingD. Surgical consultation ideally should await complete radiologic

assessment

BIRADS- -Breast Imaging Reporting And Data System

•0-incomplete study•1-normal •2-benign•3-probably benign•4-suspicious•5-highly suspicious•6-known cancer