12. Names mentioned today
in breast surgery
Paget’s disease
Sir James Paget 1874
Surgeon St. Barttholomew’s Hospital,London
Ligaments of Cooper
Sir Astley Cooper 1845
Surgeon Guy’s Hospital, London
Glands of Montgomery
William Montgomery 1837
Obstetrician, Dublin, Ireland
15. Age and Risk of Breast Cancer
• Up to age 25 1: 15000
• Up to age 30 1: 2000
• Up to age 40 1: 200
• Up to age 50 1: 50
• Up to age 60 1: 22
• Up to age 70 1: 14
• Up to age 80 1: 10
Life Time Risk 1: 8
16. Sensitivity of Mammography by Age
Age Sensitivity
30 - 39 0.58
40 – 49 0.75
50 - 59 0.92
60 - 69 0.93
70+ 0.87
Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V
(1996) Effect of age, breast density, and family history
on the sensitivity of first screening mammography.
JAMA 276: 33-38
18. Age Range
692 Operated Breast Cancer patients
250
203
200 186
150
123
99
100
52
50 26
3
0
<30 30-39 40-49 50-59 60-69 70-79 ≥80
University Hospital of North Staffordshire 2009 -2010
19. Figure 1.1: The 20 most commonly diagnosed cancers
(excluding non-melanoma skin cancer), UK, 2007
Breast
Lung
Colorectal
Prostate
N-H-L
Malignant melanoma
Bladder
Kidney
Oesophagus
Stomach
Pancreas
Uterus
Leukaemias
Ovary
Oral
Brain with CNS
Multiple myeloma
Liver
Cervix Male Female
Mesothelioma
Other
0 10,000 20,000 30,000 40,000 50,000
Number of new cases
20. Breast cancer is not
the number one killer
Cause of Death in Females 2009
35000
30000
25000
Number
20000
15000
10000
5000
0
21. Life time risk of 1:8
47,700 new cancers per annum (2008)
< 50yrs 20%
50-70yrs 50% only 33% are NHSBSP detected
>70yrs 30%
Rising Incidence over 25 years
– 50% increase (75-122/100,000)
Falling mortality
– 15% decrease (42-27/100,000)
over 550,000 ‘survivors’
8 out of 10
23. Hormonal Therapy 5 years
Tamoxifen 20mg daily for all women
Only for post-menopausal women
There is a choice of
Aromatase Inhibitors(A.I.)
Anastrazole
Letrazole
Examestane
(Primary Hormonal Therapy)
30. TWENTY-YEAR FOLLOW-UP OF A RANDOMIZED TRIAL COMPARING
TOTAL MASTECTOMY, LUMPECTOMY, AND LUMPECTOMY PLUS
IRRADIATION
FOR THE TREATMENT OF INVASIVE BREAST CANCER
BERNARD FISHER, M.D.,
ABSTRACT
In 1976, we initiated a randomized trial
to determine whether lumpectomy with or without
radiation therapy was as effective as total mastectomy
for the treatment of invasive breast cancer.
N Engl J Med, Vol. 347, No. 16 · October 17, 2002 · www.nejm.org
42. Management of the axilla
Abdul Basit et al
Diagnosis of breast cancer Clinical Breast Cancer
March 2011
Ultrasound of axilla
Suspicious Gland (S) Normal Glands
Core Needle Biopsy
(USS-CNB)
Sentinel Lymph Node Biopsy
Positive Gland Negative Gland
(SLNB)
Positive SLNB Negative SLNB
Axillary Clearance
(No further axillary treatment)
50. Breast Cancer is potentially curable
Early Detection
Nottingham Prognostic Index
(NPI) < 4.4
Size 20 mm
Grade 3
Node Negative
10 year disease free
survival = over 80 %
R.W. Blamey*, S.E. Pinder, G.R. Balla, I.O. Ellis, C.W. Elston, M.J.
Mitchell, J.L. Haybittle
The Breast Institute, Nottingham City Hospital, Nottingham
E U R O P E A N J O U R N A L OF CA N C E R
4 3 ( 2 0 0 7 ) 1 5 4 5 –1 5 4 7
51.
52. Multidisciplinary Team
• Pathologist
• Radiologist
• Oncologist
• Surgeon
• Breast Care Nurses
53. 10 Things you must know before you can plan
treatment for breast cancer
• Age
• Size of tumour 1 Margins of clearance
• Type of tumour Lympho-vascular invasion
• Grade of tumour 2 Immunohistochemistry - 3
• Lymph Node3 ER PgR Her2
Positive Negative
Health & Performance Status
If Pos, how many
nodes out of how many ?
Menopausal Status
1,2,3 = Nottingham
Prognostic Index (NPI)
59. my Ki-67 is 98%....same thing, when my oncologist said
"this is the fastest growing tumor I've ever seen"..didn't
help me much considering he is now retired and a world
reknown breast cancer specialist.....
I too had no node involvemnet. I was dx Jan of 08...my
new oncologist wants to do preventitive chemo again in
2 yrs...I am doing it, because chemo does work great
against the aggresive cells....
I am clean and clear right now....triple negative as well..
60. Educating health promoting behaviours
Weight reduction
Physical activity and exercise
30 minutes most days.
Having first child before the age of 30
Breast feeding
for 6 months during reproductive life Stockphoto.com
Diet – Less saturated and animal fat - more Fruit & Veg
•Less processed and red meat - more fish
•Less refined flour and sugar - more fibre
Avoiding hormones in the ‘pill’ , HRT and IVF
61.
62.
63.
64.
65. Ductal Carcinoma-in-Situ (DCIS)
J Cuzick, SE Pinder, IO Ellis.
Lancet Oncology 7 December 2010
The UK/ANZ DCIS trial
1694 Patients followed by yearly bilateral mammography
for a median of 12 years
376 Events (22%)
tamoxifen significant reduction in all contralateral events.
older women benefit more from radiotherapy than younger women.
66. Total events in 12 years
n =376
DCIS Invasive
197 (12%) 163 (10%)
Ipsilateral 174 (10%) 122 (10%)
Contralateral 17 (1%) 39 (2%)
Annual rate of a breast event = 2 %
ALL DIAGNOSED BY SURVELLIANCE RADIOLOGY
67. Risk factors
Family history of breast cancer in
relatives
Age at onset of breast cancer.
• Bilateral disease.
• Degree of relationship (first or greater).
• Multiple cases in the family (particularly on
one side).
• Other related early-onset tumours (for
example, ovary, sarcoma).
• Number of unaffected individuals (large families
with many unaffected relatives will be less likely to
harbour a high-risk gene mutation).
68. Known Risk Factors Gail Claus Tyrer-Cuzick
Prediction (Amir E, Evans . J Med Genet (2003) 0.48 0.56 0.81
Personal Information
Age 20 -70 years Yes Yes Yes
Body Mass Index (BMI) No No Yes
Waist to Hip Ratio No No No
Alcohol Intake (0-4 units daily) No No No
Hormonal /Reproductive Factors
Age at Menarche Yes No Yes
Age at first live birth Yes No Yes
Age at menopause No No Yes
Hormonal replacement No No No
Oral Contraceptive No No No
Breast Feeding No No No
Plasma Oestrogen No No No
Personal Breast Disease
Breast biopsies Yes No Yes
Atypical Ductal Hyperplasia Yes No Yes
Lobular Carcinoma in situ Yes No Yes
Breast Density No No No
Family history
First degree relative
Yes Yes Yes
Second degree relative
Third degree relative No Yes Yes
Age of the onset of breast cancer No No No
Bilateral breast cancer No Yes Yes
Male breast cancer No No Yes
Ovarian cancer No Yes Yes
No No Yes
Evans and Howell Breast Cancer Research 2007 9:213
69. W om an' s age i s 39 y ears . R i s k a fte r 1 0 y e a r s i s 1 1 .9 9 %.
Ag e a t m e n a r ch e w a s 1 3 y e a r s . 1 0 y e a r p o p u l a ti o n r i s k i s 1 .4 7 2 %.
Ag e a t fi r s t b i r th w a s 3 3 y e a r s . L i fe ti m e r i s k i s 3 7 .8 4 %.
Pe r s o n i s p r e m e n o p a u s a l . L i fe ti m e p o p u l a ti o n r i s k i s 9 .8 3 8 %.
H e i g h t i s 1 .7 m . Pr o b a b i l i ty o f a B R CA1 g e n e i s 7 .4 1 8 %.
W e i g h t i s 6 4 kg . Pr o b a b i l i ty o f a B R CA2 g e n e i s 6 .1 4 6 %.
W o m a n h a s n e v e r u s e d H R T.
? ?
39 39
39
37.5%
30.0%
22.5%
Pe rsona l risk
Popula tion risk
15.0%
7.5%
0.0%
39 49 59 69 79
70. “Lifetime risk is not very useful on its
own—after all there’s a 1 in 1 life time
chance that you will die of
something or other”
71. Christina
Applegate wikipedia.org
in 2010
On August 19, 2008, it was announced that Applegate was
cancer free after a double mastectomy , even though
cancer was found in only one breast.
She has an inherited genetic fault, a BRCA1 mutation.
Her mother, Nancy Priddy is a breast cancer survivor
72. TRIPLE ASSESSMENT
Imaging
History and Histopathology
Examination
Diagnostic accuracy approaching 99%
73. Lead Time Bias
Age 55
Age 50
Symptomatic
Screen detected presentation
10mm size Age 80
25mm size
76. What are the risk factors?
Known risk factors for breast cancer are:
being female
increasing age
previous history of breast cancer
having proven benign breast disease in the past
not breastfeeding long term
current use of hormone replacement therapy
having a family history of breast cancer
having no children or few children
having children at late ages (especially over 30)
early puberty
having a later menopause
obesity (for post-menopausal women only)
high consumption of alcohol
77. If you have ESTROGEN RECEPTOR POSITIVE
BREAST CANCER or a history of breast cancer in
the family and have taken IVF or long-term
HRT, there is a high probability that you have an
estrogen metabolism impairment and
were unable to process these medications
78. Each person processes medication differently. Some
women can not process (or metabolize) estrogen
correctly so when they
take certain pharmaceuticals, such as fertility drugs,
the inability to process estrogen correctly can become
carcinogenic.
Editor's Notes
Tamoxifen, the use of chemotherapy in pre menopausal, RT in WLE.The results of these improvements are an Increased number of SURVIVORS.
The local control.With a good local control the peak of relapse has shifted from year 5-6 to year 2-3..Many factors have contributed to this, Including pathological reporting of Margins, and improvement in RT, CT.
And the introduction of Immunohistochemistry 3, which gave us better treatment choices.
IN DCIS too Mammography alone have been shown to be an effective form of follow-up.
Over a period of 12 years in Breast Conserving surgery with clear margins for DCIS have shown a 2% incidence rate per year.Contralateral breast in particular with patients having a MX for DCIS is at an extremely low risk.
