BREAST CANCER:Half a million women later…

Amy Miglani M.D

September 3, 2004

PERCEPTION VS. REALITY

46% women think they will get Breast Cancer 4% women will die from Breast Cancer

36% women will die from Heart Disease 4% women think they will get Heart Disease

STATISTICS

In 2002: 205,000 women were diagnosed with Breast Cancer & 40,000 women died from Breast Cancer

Breast Cancer is the leading cause of death in women 40-55 years

30 million mammograms done yearly; 66 million screens should be done

MAJOR RISK FACTORS

Age Family History – especially premenopausal

…think BRCA1/BRCA2 Personal History of Breast Cancer History of atypical hyperplasia on biopsy

MINOR RISK FACTORS

Early menarche Late menopause Nulliparous >35yrs at first pregnancy ??HRT…

USPSTF- SCREENING MAMMOGRAPHY

Screening mammogram with or without clinical breast exam, every one to two years for women aged 40 and older.

CLINICAL CONSIDERATIONS

Evidence is strongest for women 50-69 Between 40-49, absolute benefit is less Older than 70, screening has an unclear

effect on mortality

When to stop screening becomes a judgement call.

USPSTF- CLINICAL BREAST EXAM

Evidence is insufficient to recommend for or against clinical breast exam alone to screen for breast cancer

CLINICAL CONSIDERATIONS

Most studies included both mammography and CBE, unclear what incremental benefit CBE adds

National Breast and Cervical Cancer Early Detection Program- CBE detects 5% of cancers not visible on mammography

USPSTF-SELF BREAST EXAM

Evidence is insufficient to recommend for or against teaching or performing routine breast self-examination

AN ABNORMAL MAMMOGRAM…WHAT NEXT?

BI-RADS Categories

1: Negative

2: Benign

3: Probably Benign

4: Suspicious

5: Highly suggestive of malignancy

0: Incomplete

AN ABNORMAL MAMMOGRAM

Negative/Benign- Routine screening, no intervention

Probably Benign (3)- 6mo follow up diagnostic mammogram

Suspicious/Highly Suggestive- Clinical exam. → PALPABLE- FNA or Core Biopsy NON-PALPABLE- U/S or stereotactic guided FNA or Core Biopsy

DOCTOR, I FEEL A LUMP…WOMEN WITH PALPABLE MASSES

Breast Cancer was found in 11% of women complaining of a lump

History: Location, How long, Nipple discharge, Size change, relation to menstrual cycle

Physical: Single, Hard, Immovable, Irregular borders, >2cm

PALPABLE MASS

When the woman is <35 yrs…

1) Without evidence of malignancy, have patient return in 3-10d after next menses to see if it regresses

2) If feels cystic → FNA

Clear/Green Fluid- Reassurance and f/u in 4 weeks

Bloody Fluid- Cytology

3) If doesn’t feel cystic → Ultrasound

Solid mass- FNA, Core Needle Biopsy, or Excisional

Biopsy

PALPABLE MASS

When the woman is >35…

1) Diagnostic Mammography

Negative/Benign- Repeat clinical exam

Probably Benign- Ultrasound

Suspicous/Suggestive-F/U with surgeon for tissue sample

ULTRASONOGRAPHY

Determines whether breast mass is a simple or complex cyst or a solid tumor. It is most useful for…

-Women <35

-If a mass on screening mammo can’t be felt

-Pt declines FNA of mass

-Mass is too small or too deep for FNA

FINE NEEDLE ASPIRATION

Used to determine if a palpable lump is a simple cyst

-22-24 gauge needle

-+/- local anesthesia

-Can be therapeutic if all fluid is removed

-Clear/Green Fluid- reassure patient

-Bloody Fluid- Cytology, 7% cases are cancer

CORE NEEDLE BIOPSY

Since surrounding tissue is obtained, it is useful for distinguishing atypical hyperplasia and ductal carcinoma in situ from invasive disease.

-14-18 gauge needle

-Most often for evaluating non-palpable lumps with stereotactic or ultrasound guidance

GENETICS

Inherited alterations in genes BRCA1 and BRCA2 are involved in many cases of hereditary breast cancer.

Women with these mutations are 3-7 times more likely to develop premenopausal breast cancer than those without the mutations

WHO SHOULD BE TESTED?

In 2003, the American Society of Clinical Oncology recommended testing when

1) There is family history suggesting genetic cancer susceptibility

2) The test can be adequately interpreted3) The results will aid in the diagnosis and

management of patient/family at hereditary risk of cancer

OPTIONS IF POSITIVE

Prophylactic Mastectomy Intensive Surveillance Chemoprevention with Tamoxifen

BREAST CANCER AND HRT

Women’s Health Initiative

The risk of invasive breast cancer was significantly increased with combined hormone replacement.

HRT and a positive family history appear to be synergistic risk factors. Women with both have a RR=3.4