Management of Breast Cancer: Treatment Guidelines and Prognostic Factors
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This document provides an overview of the management of breast cancer. It discusses the epidemiology, risk factors, clinical features, diagnostic imaging, biopsy procedures, pathology, prognostic factors, and treatment options for breast cancer. Treatment may involve surgery, radiation therapy, chemotherapy, hormone therapy, targeted therapy, or a combination depending on the cancer type, stage, and patient characteristics. The goal of treatment is complete resection of the primary tumor and prevention of recurrence and metastasis to improve survival.
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Management of Breast Cancer: Treatment Guidelines and Prognostic Factors
- 1. Management of breast cancer Dr. Mohammed Taofiq Registrar,Department of Surgery, UITH,Ilorin.
- 2. Outline... • Introduction • Epidemiology • Risk factors • Surgical anatomy • Clinical features • Imaging • Biopsy • Pathology • Prognostic/predictive factors • Treatment • conclusion
- 3. Introduction... • Most frequently diagnosed life – threatening cancer in women • Leading cause of cancer death in women • A major public health issue globally - 1 million new cases annually - 400,000 annual death - 4.4 million living with the dx
- 4. Epidemiology... • Prevalence is worldwide • Incidence is higher in the developed world • highest in North America,New Zealand /Australia • lowest in Asia & Sub- Sahara Africa
- 5. Epidemiology... • Mortality decreasing in the developed World • Life time risk is 1 in 6 overall & 1 in 8 for invasive disease
- 6. Risk factors... Precise etiology is unknown • Age : rises sharply with age,rare in < 25yrs • Sex : 100x commoner in female • Race/ethnicity : commoner in whites • Family history : most widely recognized breast cancer risk factors 5-10% of all breast cancers are hereditary
- 7. Risk factors... Family history : • One or more first degree relative with breast or ovarian cancer • Breast cancer occurring in an affected relative < 50yrs • Male relative with breast cancer • BRCA1 and BRCA2 mutations • Ataxia- telangiectasia heterozygotes • Ashkenazi Jewish descent
- 8. -20 -30% women with BCA have atleast one relative witness BCA -Only 5- 10% of BCA patient have an identifiable predisposed factor -BRCA 1 & 2 account for 3- 8% of BCA & 15 & 20% of familiar cases.
- 9. Risk factors ·BRCA 1 -TSG located on xsome 17 -Life time risk of developing BCA & Ovarian CA 85% & 40% -Mastectomy reduces the risk of BCA by 95%
- 10. Risk Factors · BRCA 2 -Located on xsome 13 -Increase risk of male BCA -Spectrum of associated BCA similar to non carriers
- 12. Risk factors.... Neoplastic conditions : Previous breast cancer Ovarian cancer Endometrial Cancer DCIS LCIS
- 13. Risk factors... • Benign breast diseases : Atypical lobular Hyperplasia Atypical ductal Hyperplasia Complex fibroadenoma Sclerosing adenosis Intraductal papillomatosis
- 14. Risk factors... Reproductive factors : • Menarche at < 13yrs • Nulliparity • Menopause > 50yrs • First full pregnancy > 30yrs • Less breastfeeding
- 15. Risk factors....
- 16. Surgical anatomy... • Modified sebacious gland • Ectodermal origin • Borders • Fascia • The skin • Subcutaneous tisssue • The breast tissue : stromal & epithelial • Blood supply and Lymphatics.
- 20. Imaging ... • Mammography - Primary imaging modality - abnormality on mammographic screening requires further characterization - can show microcalcification < 100microM - pick lesion 1-2yrs b4 SBE or CBE
- 21. Imaging ... • Mammography - Screening : - asymptomatic Patient - mediolateral oblique (Side) - craniocaudal (Above) - Diagnostic : - new symptoms - additional views:Spot compression Magnification
- 22. Imaging...
- 23. Imaging ... • Ultrasonography - further xterize a mammographically detected abnormality - to identify a cystic mass - alternative to mammography in dense breast - USS guided biopsy - measure & clip a lesion prior to neoadjuvant chemotherapy - improved specificity when used appropriately
- 24. • MRI - Xterization of an indeterminate lesion - Detection of occult breast cancer in px with carcinoma in an axillary LN - Evaluation of suspected multifocal or bilateral tumor
- 25. Biopsy... • A clinically suspicious mass should be biopsized,irrespective of imaging findings • FNAC • Tissue Biopsy • Open Biopsy
- 26. Other investigations... • CXR • FBC • SERUM ALP • LFT • ABDOMINOPELVIC USS • BONE SCAN • HORMONE RECEPTOR STATUS • HER2 OVEREXPRESSION
- 27. Pathology ...
- 28. Molecular intrinsic subtypes... • LUMINAL A - ER +, &/or PR+, HER2 – - Most common - Less aggressive - good prognosis - Hormone responsible - Increasing age
- 29. • LUMINAL B - ER+, &/or PR+ ,HER2 + - Worse prognosis than luminal A • BASAL LIKE - Triple Negative - Aggressive subtype - Younger ,pre-menopausal African American
- 30. • HER2 + - Less common - Highly aggressive subtype - young age - African American - Outcome improved with HER2 targeted therapy
- 31. Staging ...
- 32. Staging ...
- 33. Staging....
- 34. Staging....
- 35. Prognostic factors... • Axillary LN status • Tumor size • Lymphatic / vascular invasion • Patient age • Histologic grade • Histologic subtypes • Response to neo-adjuvant therapy • ER/PR status • HER2 gene amplification &/or overexpression
- 36. Predictive factors... • ER/PR status • HER2 gene amplification &/or Overexpression
- 37. Treatment .. • Multimodality & Multidisciplinary • Surgery is the primary treatment modality- early stage,cured with surgery alone • Aim of surgery is complete resection of the primary tumor with negative margins & pathologic staging of the tumor & Axilla
- 38. • Adjuvant therapy : radiation therapy(RT), chemotherapy, hormonal and Targeted therapy • Neo- adjuvant therapy
- 40. DCIS • Surgical resection + or – radiation • ALND or SLNB not routinely recommended • Tamoxifen Only approved agent in px rx with BCS • A precusor of invasive dx. • Account for 5% of male breast cancer
- 41. LCIS • Observation & close follow up care with or without tamoxifen • Bilateral mastectomy with or without reconstruction • Risk of invasive cancer is low(25-30%) & equal in both breast.
- 42. Treatment- Early Breast Cancer(I &II or T1-3,N0-1,M0) • Loco – regional disease : surgery &/or radiation therapy • Systemic disease : one or combination of chemotherapy,hormonal or biologic therepy
- 46. Indications for Mastectomy ·Tumor size > 5cm ·Multicentric cancers ·Local recurrence ffg BCS ·Centrally located tumours ·No facillity for radiotherapy
- 47. INDICATIONS FOR MASTECTOMY *prior radiation therapy to the breast or chest wall *Radiotherapy contraindicated In pregnancy *Inflammatory breast cancer *Persistent positive pathologic Margin *Active connective tissue dx
- 48. Radiotherapy ... • Routine in BCS,May be indicated post mastectomy • Aim is eradication of local residual subclinical dx & minimize local recurrence rates • 2 approaches : EBRT or PBI
- 49. Post Mastectomy RT- Indications • Positive post mastectomy margins • Primary tumors larger than 5cm • Involvement of 4 or More LN • Skin or Chest wall involvement
- 50. Side effects of RT... • Fatigue • Skin desquamation • Breast pain • Breast swelling • Rib # • Pulmonary fibrosis • Cardiac dx • Secondary malignancies
- 51. Treatment of the Axilla...
- 52. Indications for ALND *Preoperative diagnosis of +ve ALND *Prior Inadequate ALND *+ve Intraoperative SLNB *Failed Mapping of SLNB *Clinically suspicious nodes at surgery
- 53. Axillary treatment... • ALND or SLNB • SLNB :Indicated in clinically node Negative px • Single modality for axillary treatment
- 54. ALND...
- 55. SLNB...
- 56. Adjuvant systemic therapy... • Aim is to prevent recurrence & improve overall survival • Choice of therapy depend on : - hormone status - menopausal status - HER2 status - risk of recurrence & potential benefit • Combination therapy
- 58. Treatment of advance breast cancer
- 59. LABC... • Advance primary tumor ie > 5cm • Skin &/or chest wall involvement • Advance regional LN involvement • IBC Multimodality Rx involving surgery,radiotherapy and systemic therapy Neoadjuvant systemic therapy is usual
- 60. Neo adjuvant therapy.. • Aim is to improve surgical outcome & surgical options - operable BC,Increase the chances of BCS -Inoperable, LABC: Achieving operability
- 61. LABC • Locoregional Rx is based on tumor response to neodjuvant • Consist of surgery-either mastectomy or BCS & post operative RT • surgery should be done ONLY if a macroscopically complete resection is possible
- 65. recurrence dx... • Post BCS : Total mastectomy + adjuvant chemotherapy or endocrine therapy • Post MRM : local resection of recurrence where feasible + radiotherapy if no RT b4.
- 66. Metastatic disease.. • Aim is to palliate symptoms,prolong survival,maintain QOL • Visceral metastasis- poor prognosis • Chemotherapy is indicated for hrme insensitive MBCA • Hormone therapy preferred when ever applicable
- 67. Conclusion... • Breast cancer survival rates have increased significantly, particularly in younger women. • The need for increased public awareness & early detection cannot be overemphasized.
Notas do Editor
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