Download - Breast Cancer Protocol
Western Visayas Medical CenterHospital Cancer Committee
Most common site-specific cancer in women worlwide2nd most common cause of cancer death in women5th most common cause of death in women8-12% lifetime risk of developing breast cancer
Most common cancer in female being treated in the wards (20 surgical cases admitted for 2008) Majority of patients in Clinical Stage IIb, III and stage IV Majority of patients in Pathologic stage III Treatment is mostly surgical Poor follow-up
Breast mass – 33%Others
Nipple changes (retractions, discharges)Ulceration/erythema of the skin of
breastsBreast enlargement/asymmetryAxillary mass
Early Detection
1. Breast self-exam (BSE) every month starting the age of 20. (1-2 weeks after 1st day of menstruation.
2. Clinical breast exam (CBE) starting the age of 20 and every 3-5 years thereafter
3. Clinical breast exam at the age of 40 then yearly thereafter.
4. Mammography starting at the age of 40 then yearly thereafter.
5. Mammography at age 35 for high risk patients.
Hormonal risk factors Early menarche Nulliparity Late menopause Obesity Hormonal pills/HRT
Nonhormonal risk factors Old age First degree relatives with breast cancer Radiation therapy Alcohol consumption High fat diet
I - 94%IIa - 85%IIb - 70%IIIa - 52%IIIb - 48%IV - 18%
Mammography* - 30% reduction in mortality rate from breast cancer
Screening mammography - women with no symptoms Diagnostic mammography - women with symptoms
Breast Ultrasound – adjunct to mammography Ductography* - for women with bloody nipple dischargesMRI* - for high risk patients with dense breast during mammography
Surgery Breast conserving surgery (lumpectomy, quadrantectomy) Mastectomy Modified radical mastectomy
Chemotherapy* Adjuvant chemotherapy Neoadjuvant chemotherapy
RadiotherapyHormonal therapy*
Antiestrogen (Tamoxifen) – hormone receptor (+) pre and postmenopausal 25% reduction in breast cancer recurrence 7% reduction in breast cancer mortality
Aromatase inhibitors (anastrozole/letrozole)- hormone receptor (+) postmenopausal
Biologic therapy*- antiHER2/neu antibody therapy (herceptin/trasruzumab)Ablative endocrine surgery
Breast cancer stagingStage I
Primary tumor is 2 cms or less with no lymphatic spread
Stage IIIIa – no tumor but 1-3 positive axillary nodes;
primary tumor is 2 cms or less with (+) 1-3 axillary lymph nodes, (+) SLNB; tumor 2-5 cms with no axillary spread
IIb – primary tumor is 2-5 cms with spread to 1-3 axillary lymph node; tumor >5 cms with no axillary spread
Breast cancer stagingStage III
IIIa-no tumor but with 4-9 axillary lymph node; <5cms but with 4-9 axillary lymph node; >5 cms but does not grow into chest wall or skin
IIIb-tumor has grown into chest wall and skin with no axillary lymph node or with 1-3 lymph node; or 4-9 lymph node
IIIc-tumor of any size with spread to 10 or more axillary lymph node or supraclavicular lymph node
Stage IVSpread of breast cancer to distant areas of the
body
Treatment Pathways
Non- Palpable Breast Mass
Image Guided Biopsy (Ultrasound/
mammography)
Malignant Benign
Observe
Breast Ultrasound/Mammograp
hyMammogra
m/Stereotactic needle not available
History/PE
Normal Clinical Breast Exam, <low
risk, <40 yo
Doubtful clinical breast exam, high risk,
>40 years old
(+) lesions
(-) lesions
Palpable Breast Mass
Biopsy (FNAB/Excision or incision
biopsy)
Malignant Benign
Non-invasiveDCISLCIS
InvasiveInfiltrating Ductal CA,
others
Observe
Clinical StagingA.Early Stage (I-
IIIA)B.Late Stage (IIIB-
IV)
Hx and PE
>40 any size, high risk, <40 but mass
2cm or more
<40, <2 cms in size, low risk
Complete excision if incision biopsy
was done
Early Breast Cancer(DCIS, Stage I,II,IIIA)
Mastectomy/Modified Radical Mastectomy
Breast Conserving Surgery (with axillary
dissection)
Hormone Receptor
Hx/PE, CBC,CXR,
LFT, mammogram, ER/PR,HER-2
Axillary Nodes
(+) (-)
Chemotherapy
Tamoxifen
Aromatase inhibitors
Radiotherapy
High nuclear grade,high histologic grade, HER2 +
may proceed with chemotherapy
Observe
HER2/neu (+) tumors may be started with Herceptin
(+) (-)Oophorectomy
for premenopausal
Postmenopausal
Advance Stage Breast Cancer (Stage IIIb-IV)
Chemotherapy
Modified Radical Mastectomy/Mastecto
my
Breast Conserving Surgery
Adjuvant Chemotherapy
Radiotherapy
Tamoxifen
Aromatase inhibitors
Hormone Receptor (+)
Hx/PE, CBC,CXR, LFT, mammogram,
ER/PR,HER-2, hepatic UTZ, bone
scan
HER2/neu (+) tumors may be started with
Herceptin
Postmenopausal
Recurrent Breast Cancer (loc0regional
and distant metastasis)
Biopsy (for local recurrence)
Chemotherapy
Radiotherapy
Hospice Care
Hx/PE, CBC,CXR, LFT, mammogram,
ER/PR,HER-2, hepatic UTZ, bone
scan
Sentinel lymph node biopsyUse for women with T1 and T2 N0 breast
cancer(+) sentinel node biopsy
Axillary dissection and node clearance necesary
(-)sentinel node biopsyAxillary dissection not necessary
Predict prognosis and response to therapyPredict more accurately the disease free and overall survival rate than clinicopathologic stagingThese tumors tend to grow faster and recur more oftenEGFr and HER2/neu overexpression signifies high nuclear grade and high proliferation aneuploidyTrastuzumab(Herceptin)52% decrease in breast cancer recurrence
BRCA-1 and BRCA-2Tumor suppressor geneBRCA-1
90% lifetime risk of developing breast cancerBRCA-2
85% lifetime risk of developing breast cancerCancer prevention for BRCA mutation carriers
Prophylactic mastectomy Prophylactic mastectomy and HRT Intensive suveillance Chemoprevention
BCS vs MastectomyFactors why women choose mastectomy over
BCSFear of recurrence in remaining breastFear of dying from breast cancerHigh cost of radiation with BCSDistance from radiation facilityOlder women favor mastectomy
Chemotherapy regimen Node negative women
CMFFACAC
Node positive womenFAC or CEFAC +/- TA – CMFCMFEC
Thank you and good morning.