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Breast Cancer 2020What’s new?
Dr. Patti Ann Stefanick, D.O., F.A.C.O.S.
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Disclosures
• I have no relevant conflicts to disclose.
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What’s new in Breast Cancer?
Facts and FiguresStagesDetectionDiagnosisInterventionTreatment
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Breast Cancer Statistics - 2019
268,600 new cases invasive cancer diagnosed in women62,930 new cases in situ cancer diagnosed in
women2,670 new cases diagnosed in men42,260 deaths last year37% decrease in death rate over last 20 years
BREASTCANCER.ORG/STATISTICS 2019
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Breast Cancer RiskUp to age Women’s odds 25 1 in 19,608 30 1 in 2,525 35 1 in 622 40 1 in 217 45 1 in 93 50 1 in 50 55 1 in 33 60 1 in 24 65 1 in 17 70 1 in 14 75 1 in 11 80 1 in 10 85 1 in 995 1 in 8 NCI 2018
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Risk Factors for Developing Breast Cancer
Never having children Having your first child after age 30 Drinking more than 1 alcoholic drink/day Overweight Family history of breast cancer Personal history of ovarian cancer First menses before age of 12 Menopause starting after age of 55 Breast biopsy showing atypical cells Having gene mutation (BRCA1, BRCA2)
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Presenting Signs and Symptoms Lump in Breast
– 80%– Usually painless
Change in Nipple– Discharge– Retraction– Enlargement
Breast Redness Axillary Mass Swelling of Arm Bone Pain
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Prognostic FactorsStage of diseaseNumber of involved axillary lymph nodesTumor sizeTumor DifferentiationAneuploidy (abnormal chromosomal number)Cells in S-phase or cell cycleCopies of oncogene HER-2/NEU
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Breast Cancer Survival
Relative survival rates (ACS, 2017 data) 92% at 5 years after diagnosis 83% after 10 years 78% after 15 years
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Factors that influence surviving when diagnosed with breast cancer:
Stage at diagnosisRace/ethnicitySocioeconomicTumor CharacteristicsTime since diagnosisAge at diagnosisACS 2015
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Frequency of Axillary Node Involvement Related to Tumor Size
Tumor size (cm) Frequency of node involvement(%) < 0.5 20.6 0.5-0.9 20.61.0-1.9 33.22.0-2.9 44.93.0-3.9 52.14.0-4.9 60.0>5.0 70.1
(Carter, et al, CANCER, 1989)
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Stages of Breast Cancer
Stage 0: Non-invasive beast cancerStage 1A: invasive cancer up to 2cm, no
lymph node involvementStage 1B: No breast tumor, only lymph node
involvement OR breast tumor <2cm and small groups of cells in the lymph nodes
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Stages of Breast Cancer(continued)
Stage 2A: Tumor up to 2cm and has spread to lymph nodes OR tumor 2 – 5 cm and no lymph nodes Stage 2B: Tumor 2 – 5 cm and spread to lymph
nodes OR Tumor 2 – 5 cm and in 1 – 3 lymph nodes OR Tumor >5 cm and negative nodes
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Stages of Breast Cancer(continued)
Stage 3A: No tumor in breast but in 4 – 9 lymph nodes OR Tumor >5 cm and small groups of tumor cells in lymph nodes OR Tumor > 5 cm and in 1 – 3 lymph nodes
Stage 3B: Any size tumor and spread to up to 9 nodes OR Inflammatory Breast Cancer, involving redness, swelling, possible ulcer of skin
Stage 3C: Tumor of any size and >10 nodes OR spread to nodes near clavicle or collarbone
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Stages of Breast Cancer(continued)
Stage 4: Tumor that has spread beyond the breast and axilla to distant lymph nodes, skin, lung, liver, bone, or brain
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Most common Types of Breast Cancer
Ductal Carcinoma – in – situ (DCIS)Lobular Carcinoma – in – situ (LCIS)Infiltrating Ductal Carcinoma (IFDC)Infiltrating Lobular Carcinoma (IFLC)
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Ductal Carcinoma – in situ (DCIS)
Completely contained within terminal ductulesHistologic types:
- Comedo-Cribriform-Cobweb-Papillary
Comedo is most likely to become invasive
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DCIS
20 – 30% progress to invasive cancerPresents as:
Gross: mass or Paget’s DiseaseMicroscopic
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DCIS – Progression of Disease
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DCIS
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DCIS
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DCIS – Paget’s Disease
Sir James Paget – England, 1814-1899Eczematous changes – areola and nipple1 – 4% of all breast cancers60% with associated breast mass
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Paget’s Disease
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Paget’s Disease
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DCISGross DCIS – treat like IFDCMicroscopic DCIS:
Most common form of DCIS todayFound on screening mammogramsPrecipitation of calcium into lumen of
abnormal ductTreatment: total mastectomy
limited resection and radiationlimited resection and observation
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DCIS in Mammogram
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DCIS - Microscopic
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DCIS - Microscopic
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Lobular Carcinoma – in Situ (LCIS)
Tumors confined to breast lobulesFirst described in 1941Incidence unknownMicroscopic, non-palpableFound incidentallyMammography useless
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LCIS
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LCIS
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LCISHaagenson (Columbia, NYC)
“Lobular neoplasia”Gump(Columbia) – “predictive factor”
predicts IFDC, not invasive lobularStrong marker – 37% progress to IFDC (Rosen,
MSKCC)High % bilaterality
25% risk (Columbia)35% risk (MSKCC)
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LCISTreatment – 3 options
Observation (Columbia)includes breast MRI
Ipsilateral mastectomy +/- contralateralbiopsy (MSKCC)Bilateral mastectomies
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LCIS
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LCIS DCIS Premenopausal
No physical findings
No metastasis
Bilateral risk of cancer
• No Microcalcifications on film
•
Pre & postmenopausal
No mass with micro form Mass with gross form
No mets with micro form Possible mets with gross form
Unilateral risk of cancer
Microcalcifications on film
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Infiltrating Ductal Carcinoma (IFDC)
73% of all breast cancers in U.S.Begins in duct and extends through itMay be stellate or circumscribedHistologic grading:
well-differentiatedmoderately differentiatedpoorly differentiated
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DCIS
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IFDC - Microscopic
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Infiltrating Ductal Carcinoma
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IFDC
Treatment options:Total mastectomy with axillary sentinel node
biopsy +/- dissection – with or without reconstructionLimited resection and axillary biopsy(sentinel
node) +/- dissection and radiation treatment (LART)
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Infiltrating Lobular Cancer
10 – 14% of all invasive carcinomasArises from mammary lobules, then infiltrates
in a linear arrangement of tumor cells that wrap around ducts and lobulesUsually accompanied by LCIS tumors
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Infiltrating Lobular Carcinoma
Mammography: no calcifications multifocalno definitive marginsbilateral in 6 – 28% cases
Treatment as per IFDC: Mastectomy + node bxLART
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Infiltrating Lobular Cancer
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Adjuvant Therapy for Breast Cancer
Definition
Systemic therapy given at the time of primary local treatment in the absence of demonstrated metastasis
Chemotherapy : used in adjuvant setting or to treat metastasis
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Chemotherapy Always used in “node +” women Often used in “node –” women Chemotherapy for “node –” women
- Based on 1988 NCI Clinical Alert (Davita)- High nuclear grade, poor differentiation,
high # mitotic figures, vascular or lymphaticinvasion
- oncogene testing essential today- tumor size, high # nodes- Clinical trials are valuable and ongoing
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Adjuvant Therapy
Hormonal manipulation* Estrogen receptor antagonist
- Blocks estrogen receptors to prevent estrogen-fed tumors from feeding on estrogen
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Preoperative Chemotherapy
Used in locally advanced tumorsEffectively shrinks tumors prior to surgery to
assist in breast conservationCan clear a microscopically “+” axilla
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Radiation TherapyUsed in conjunction with breast conserving
surgery for IFDCNSABP B-06 first showed equal survival to
Mastectomy patientsDecreases local recurranceUsed to decrease tumor bulk in locally
advanced cases
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Locally Advanced Breast Cancer
Chemotherapy prior to surgeryMay rely on radiation treatment instead of
surgery to reduce tumor bulk
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Metastatic Breast Cancer
Most common sites: BoneLungLiverBrain
Treatment includes chemotherapy and radiation
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Genetic Testing BRCA-1 and BRCA-2 genes isolated Shows increased susceptibility to breast, ovarian,
pancreatic and melanoma cancer, and prostate cancer in men
Useful in patients with family histories of breast and ovarian cancer
Screenings in larger centers along with genetic counseling, kits in private offices (Myriad)
Carriers choosing prophylactic mastectomies (17%) and oophorectomies (33%)
Increasingly covered by insuranceMAYO CLINIC 2019
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The best way to diagnose breast cancer early for early treatment:
MAMMOGRAPHY
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Mammography: Two typesScreening Age 40, annually thereafter Asymptomatic Negative physical examination Patients with a first-degree relative with breast cancer
should begin screening 10 years earlier than the age the relative was diagnosed
Diagnostic Symptomatic Findings on physical examination Questionable finding on screening mammogram
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Mammography
Film mammography is now obsoleteDigital mammography, images recorded on a
computer, are now the standard of care.3-D mammography, or breast tomosyntheses,
combines multiple breast X-rays to create a 3D picture of the breast. They improve breast cancer detection in dense breast tissue.
The level of radiation in a 3-D mammogram is greater than that of a digital mammogram alone.
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So why is breast density important?
Women with extremely dense breast tissue have a 4 to 6 times greater risk of getting cancer than fatty breasts. JAMA2012
Mammograms detect 98% of cancers in women with fatty breasts but ONLY 48% in women with dense breasts.
Gov. Corbett signed the Breast Density Notification Act, in 2013, making Pennsylvania the 17th state to require notification to patients of their breast density.
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Breast Density Scale
1 Almost entirely fatty 10% 2 Scattered fibroglandular tissue 40%3 Heterogeneously dense tissue 40%4 Extremely dense tissue 10%
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BIRADS
Stands for “Breast imaging Reporting and Data System”Used by radiologists to standardize
mammography, ultrasound, and MRI reporting
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BIRADS Categories
Category 0
1 2 3
4 5 6
Assessment
Incomplete – needs more imaging
Negative Benign findings Probably benign – “I’m not
sure” – short follow-up Suspicious abnormality Highly suggestive of cancer Biopsy-proven cancer ACR 2013
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Breast Ultrasound
Use of sound waves to penetrate breast tissue and find cystic or solid lesionsUsed to complement mammography, not
instead of itUseful in dense breast tissueUltrasound reveals 28% more cancers in at-
risk women than mammogram alone
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Breast MRI Use of MRI imaging technique to further visualize
dense breast tissue or to evaluate palpable lesions not seen on mammogram or ultrasound
Useful in high risk patients Useful in every new breast cancer patient to identify
multifocal diseaseMay use MRI to biopsy lesions not seen on
mammogram or ultrasound Not used in place of screening mammography Useful in women with implants OFTEN NOT COVERED BY INSURANCE!!!!!! ACS March 2007
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BREAST CANCER DIAGNOSIS
Early detection of breast cancer greatly improves treatment options, chances of successful treatment, and survivalTo make a definitive diagnosis , a biopsy must
be performed80% OF BREAST BIOPSIES ARE BENIGNAJR(1995)165:1373-77
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Diagnosis: The shift in care
Open Surgical biopsy
Performed in the operatingroom
Minimally invasive biopsy Performed in a doctor’s
office As accurate as open surgical
biopsy Stereotactic biopsy Vacuum-assisted core
biopsy FNA
RADIOL CLIN NORTH AM.200;38:791-807
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Stereotactic Breast Biopsy
Minimally invasive breast biopsy technique for non-palpable breast lesions seen on mammogramComputerized system based on geometric
principlesFisher, Lorad
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Locates the abnormality in the breast in three dimensions (horizontal, vertical, depth).
Uses the same visual principles that our brain and our eyes use to see in three dimensions.
Stereotactic (X-Ray) Guided Biopsy
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Stereotactic
Parker S. Lesion Workup and Selection for Biopsy, Breast Imaging and Intervention in the 21st Century. 10/23/02, Key Largo, FLBassett LW, Winchester DP. Stereotactic core-needled biopsy of the breast. ACS and College of Amer. Pathologists CA Cancer J (1997);47:171-190
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• Granular Calcifications• Dense, pleomorphic calcifications, lobular• Dense, pleomorphic calcifications, ductal*• Irregular shape• Spiculated or ill-defined margins• Microlobulations• Associated findings, such as focal skin
thickening and focal solitary dilated duct
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Ultrasound-Guided Breast Biopsy
Minimally invasive breast biopsy technique for masses seen on ultrasoundVacuum-assisted biopsy techniqueFor palpable and nonpalpable lesions
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Ultrasound Guided Biopsy
Locates the abnormality in the breast using high frequency sound waves.
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• Lesions < 1 cm• Indeterminate lesions• Heterogeneous lesions:• Papillary lesions• Complex cysts• Irregular shape• Spiculated or ill-defined margins.• Microlobulations• Associated findings, such as focal skin thickening
and focal solitary dilated duct.
Ultrasound
Fine RE, Staren ED. Updates in Breast Ultrasound. The Surgeons Clinics of NA (2004)
Bassett LW, Winchester DP. Stereotactic core-needled biopsy of the breast. ACS and College of Amer. Pathologists CA Cancer J (1997);47:171-190
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Sentinel Node BiopsyMinimally invasive technique to stage the
axilla in a patient with breast cancerTheory that nodal involvement ascends the
chain, very rarely skips low nodes to involve higher nodesInjection of isosulfan blue and
Radiopharmaceutial (Tc99) will identify the first node of drainage in 92% cases
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Sentinel Node BiopsyNode in axilla will be nucleoactive (“hot”)
bright blue, or bothAverage number of sentinel nodes obtained
per case = 2.2 nodesIf sentinel node + , may proceed with axillary
node dissection; may instead proceed with chemotherapy in some casesIf no sentinel node is identified, must do
axillary node dissection
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Gamma Probe Spectrum for I-125 and Tc-99m
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Why Sentinel Node Biopsy? Accurately stage the axilla in large % women Fewer nodes out means less morbidity:
lymphademaAxillary seromasintercostal brachial nerve syndromepost-op infections
Lower cost Less anesthesia Usually limited to tumors <3 cm and nonpalpable
lymph nodes (clinical stage I and II) Very useful to stage axilla after preop chemo given
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Male Breast Cancer
1% of all breast cancer in USAMale lifetime risk of breast cancer = 1 in 883 In 2019, 500 men died of the diseaseFirm, painless unilateral massUsually presents as more advanced stateTreatment as per female – higher % modified
radical mastectomies and post-op radiation
AMERICAN CANCER SOCIETY STATS 2019
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Breast Cancer…
Early diagnosis is the key to survival!