1. Dr. Asghar H. Asghar, FCPS
Oncologist, KIRAN, Karachi

2.  It is the most common cancer in female
 Second leading cause of cancer death after
CA lung
 Worldwide incidence more than one million
per year
 90,000 in Pakistan
 40,000 expire in Pakistan

3.  Age 20-29: 1 in 2,000
 Age 30-39: 1 in 229
 Age 40-49: 1 in 68
 Age 50-59: 1 in 37
 Age 60-69: 1 in 26
 Ever: 1 in 8
 Source: American Cancer Society Breast Cancer Facts & Figures, 2005-2006.

5.  Incidence in Asia is highest in Pakistan
 In 70%, cause is unknown
 Certain risk factors are there
 Most of the cases are diagnosed in stage III
and IV
 People don’t want to consult doctors due to
certain stigma

6.  Old Age
 Early menarche
 Late menopause
 First child birth (>30
years)
 Nulliparous
 Personal history of
breast cancer
 Family history in 1st
degree relatives
 Post-menopausal HRT
 Previous suspicious
breast biopsy
 Hereditary syndromes
(BRCA-1 & 2)

7.  Familial
 Fifty
 Female
 FattyAcids (saturated)
 Fortune

9. stage 5-year survival rate
0 93%
I 88%
IIA 81%
IIB 74%
IIIA 67%
IIIB 49%
IIIC 41%
IV 15%

10.  Clinical Evaluation – Lump and regional
nodes
 Imaging (ultrasound <35 years old or
mammography >35 years old)
 Cytology or Histology

11.  Clinical Evaluation – Lump and regional
nodes
 Imaging (ultrasound <35 years old or
mammography >35 years old)
 Cytology or Histology

12.  Best done a week after the period, when
breasts are not tender or retaining fluid
 Stand in front of a mirror with hands on hips
 Look for signs of dimpling, swelling, soreness
on palpation, or redness
 Repeat this with arms over head

13.  Palpate breast in quadrants or in a circular
motion
 Repeat palpation exam when lying down
 Check axillary tail of each breast for
enlarged lymph glands
 Check nipples and area just beneath to it
 Gently squeeze nipples to detect any
discharge

14.  Hard, irregular and painless
 Malignant masses are painful in only 10-
15% of patients.
 Skin dimpling
 Nipple retraction
 Bloody or watery discharge
 Possibly fixed to the skin or chest wall

15.  X-ray of breast for detection of tumors
too small to be palpated
 First (baseline) between ages 35-40 years.
 Annually after age 40.

16.  Highly sensitive test
 Sensitivity is reduced
in young women due
to the presence of
high glandular tissue

19. Mammographic Findings

21.  Differentiate solid
vs cystic lesions
 Sensitivity 75%
 Specificity 97%

22. • Simple
• Easy to perform
• Cheap
• Not time consuming
• Negative FNAC doesn’t exclude cancer

23. • It is needed when FNAC is negative
• Also simple
• Done on OPD basis
• No operation
• Mild local anesthesia
• More reliable than FNAC

27. ER Positive ER Negative
Proportion of
patient
75% 25%
Mean age (Years) 63 57
<50 years 20% 35%
≥50Years 80% 65%
>2 cm 29% 41%
≤2 cm 65% 50%
Anderson WF et al. Breast Cancer Res Treat 2002; 76: 27–36

29.  Detailed clinical history
 Thorough physical examination
 Diagnostic workup
 Treatment
 Surgical
 Chemotherapy
 Radiotherapy
 HormonalTherapy
 TargetedTherapy

30.  Routine blood examination
 CXR, USG abdomen or CT Chest and abdomen
 FNAC, Core needle biopsy
 Bone scan
 ER/PR and HER-2 neu status
 Ki-67, CA-15-3
 Echocardiography/MUGA scan
 p53, BRCA-1 and BRCA-2

31.  To cure the disease and improve the survival
 Relief of symptoms
 To minimize the risk of recurrence
 Return to a quality of life as before diagnosis
 To minimize cosmetic issues

33.  DCIS may never invade but long term data shows
that 30-50% do invade in 10 years if left untreated .
 Total Mastectomy (TM) or Lumpectomy (L) with or
without radiation.
 Radiotherapy should be considered for women with
DCIS where conservation is desired.
 Axillary lymph node dissection is not necessary in
the management of most patients with DCIS.

34.  20-25% LCIS invade in 10-20 years.
 Annual physical examination & annual
bilateral mammography appears to be the
best management option
 Lumpectomy or total mastectomy with or
without contra-lateral prophylactic
mastectomy
 Close follow-up in the key point

35.  Treatment depends on following factors:
 Clinical extent
 Pathological characteristics
 Prognostic factors
 Patient age (menopausal status)
 Patients preference and the psychological profile

36.  Two surgical options:
 Breast conservation Surgery (BCS)
 Modified Radical Mastectomy (MRM).
 MRM should be considered in:
 Patient preference, no cosmetic problem.
 Large tumor in small breast.
 High risk for local recurrence.
 Diffuse micro-calcification or multi-centric
disease.
 Unreliable for further follow0up.

38.  Pre-treatment ofTru-Cut biopsy
 Tumor localization with surgical clips
 Sentinel Lymph Node (SLN) biopsy for
clinically negative axilla
 Tru-cut or FNAC or SLN biopsy for clinically
positive axilla

39.  If SLN negative before neoadjuvant: omit
axillary clearance
 If SLN positive before neoadjuvant: axillary
clearance required
 If SLN not done before neoadjuvant: axillary
clearance required

40.  pCR (26%) was observed more in patients
who completed Neoadjuvant chemotherapy
(NSABP-27)
 If neoadjuvant is not complete then will be
completed in adjuvant setting
 No role of further chemotherapy if completed
neoadjuvant

41.  BCS rate higher after neoadjuvant
 However, no disease specific survival
advantage as compared to adjuvant
chemotherapy in stage-II

43.  Both clinical and pathological response (26%)
was higher in AC-T arm as compared to AC
(14%) arm
 Docetaxel was not superior to AC in DFS and
OS

44.  Paclitaxel x4 F/B FECx4
 Paclitaxel x 4 +Trastuzumab x 24 weekly F/B
FEC x 4
 No. of patients 42
 All were treated in neoadjuvant setting
 J Clin Oncol. 2005 Jun 1;23(16):3676-85. Epub 2005 Feb 28

45.  pCR more in favor ofTrastuzumab
 26% vs 65%

46.  Many trials have been done in post-
menopausal ER positive patients
 Improved clinical response and higher rate of
BCS in patients who used AIs as compared to
SERMs
 Letrozole and Anastrozole has superior
results

47.  Pre-meno. Node +ve and ER –ve pts:
 FAC, AC-T,TC, CMF for 4-6 months.
 Pre-meno. Node +ve and ER +ve pts:
 Chemo + HT (Goserline/Ovarian
Ablation,Tamoxifen, Anastrazole)
 Pre-meno. Node –ve & ER +ve pts:
 Chemo + HT
 Post-meno. Node +ve and ER -ve pts:
 Chemo only. No HT
 Post-meno. Node –ve & ER +ve pts:
 Chemotherapy + HT

48.  Adjuvant online

49.  Mandatory in breast conservational surgery
 Mandatory after MRM if >5 cm, node
positive, close margin,

50.  It is indicated in the following:
 Three or more metastatic lymph node.
 Any lymph node > 2.5 cm
 Involvement of apex of axilla
 < 10 lymph node removed??
 Gross extra-capsular tumor extension.

51.  If not giving chemo, then best to start within
4-6 weeks.
 If chemo is being given then should be
started within 4-6 weeks after completion of
chemo.

52.  Arm or breast edema
 Breast fibrosis
 Painful mastitis or myositis
 Pneumonitis.
 Apical pulmonary fibrosis
 Rib fracture (rare)

54.  Chemo, irradiation, surgery and hormonal
therapy are the options
 MRM is the best option for all resectable
tumors.
 Neoadjuvant chemotherapy with or without
hormone therapy is also another good
option.

55.  Lesion > 5 cm
 Any skin, fascial or skeletal muscle involvement
 Poorly differentiated tumors??
 Positive or close surgical margins (<1 mm).
 Lymphatic permeation, matted L.N or > 3 LN
involved.
 < 10 LN removed
 Gross extracapsular tumor extension

56.  Increasing tumor size
 Higher histological grade
 Presence and number of lymph node
metastases
 Estrogen-receptor negative
 Progesterone-receptor negative
 HER-2-neu positive

57. Tamoxifen
x 5 years
ER(-)PR(-)ER(+) or PR(+)
no further
treatment
surgery +/- radiation +/- chemotherapy
Tamoxifen
contraindicated and
postmenopausal
Adjuvant Treatment
AIs
x 5 years
AIs
x ? years
High RiskLow Risk
no further
treatment

58.  Reduced the risk of recurrence annually by
39%
 Reduces the risk of annual mortality by 31%
 MA-17 trial showed the survival advantage
with extended use of Letrozole (Femara)
compared with placebo
 Another good options inAIs now available is
Aromasin (Exemestane)

60.  Mastectomy is the best option.
 Irradiation to chest wall only ?
 Due to low nodal metastasis, irradiation to
axilla is not advocated.

61.  Our patient needs detailed counseling that
surgery is not the only treatment
 Surgery if done well in time will be the
turning point for success
 Multidisciplinary team approach is the key
point in this management
 Without this, we can say that our patient may
not be receiving adequate treatment