File #2File #2

Basic Breast CancerBasic Breast Cancer

Oncology Rehabilitation: Web-based Learning for Physical Therapists Who Provide Rehabilitation to Patients with Breast Cancer

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Basic Breast CancerBasic Breast Cancer

• General oncology information that will assist General oncology information that will assist physical therapists who desire to work with physical therapists who desire to work with patients diagnosed with breast cancer.patients diagnosed with breast cancer.

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Who can get Cancer?Who can get Cancer?

• AnyoneAnyone– 1,382,400 new diagnosed cases/year1,382,400 new diagnosed cases/year– 269,730 new breast cancer/year269,730 new breast cancer/year

– 1 in 7 women are diagnosed with breast cancer1 in 7 women are diagnosed with breast cancer

(www.cancer.org, 2006)

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CancerCancer2nd most common cause of 2nd most common cause of death in the United Statesdeath in the United States

• Uncontrolled growth and spread of abnormal Uncontrolled growth and spread of abnormal cells can result in death.cells can result in death.

• Over 9.8 million Americans alive today have Over 9.8 million Americans alive today have a history of cancer. (3 million in 1971)a history of cancer. (3 million in 1971)

• About 547,000/year people will die of cancer.About 547,000/year people will die of cancer.

• About 500,000 (4 of 10) people diagnosed About 500,000 (4 of 10) people diagnosed with cancer will be alive in 5 years.with cancer will be alive in 5 years.

(www.cancer.org, 2006)

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Breast Cancer Specific:Breast Cancer Specific:

• The American Cancer Society estimates in 2006 that …The American Cancer Society estimates in 2006 that …– there will be 212,920 new cases of invasive breast cancer there will be 212,920 new cases of invasive breast cancer

to be diagnosed, and 61,980 non-invasive cases.to be diagnosed, and 61,980 non-invasive cases.– approximately 40,970 females are expected to die from approximately 40,970 females are expected to die from

breast cancer.breast cancer.– about 1,720 cases of breast cancer expected in men, about 1,720 cases of breast cancer expected in men,

accounting for <1% of all breast cancer. Approximately accounting for <1% of all breast cancer. Approximately 460 men will die of this diagnosis.460 men will die of this diagnosis.

• The National Cancer Institute estimates about 2.3 The National Cancer Institute estimates about 2.3 million women with a history of breast cancer were alive million women with a history of breast cancer were alive in 2002.in 2002.

(American Cancer Society, www.cancer.org, 2006)

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DORLAND’S ILLUSTRATED DORLAND’S ILLUSTRATED MEDICAL DICTIONARYMEDICAL DICTIONARY

• ONCOLOGYONCOLOGY (Ong-kol’o-je) The sum of knowledge (Ong-kol’o-je) The sum of knowledge concerning tumors; the study of tumors.concerning tumors; the study of tumors.

• CANCERCANCER (Kan’ser) A cellular tumor the natural (Kan’ser) A cellular tumor the natural course of which is fatal and usually associated course of which is fatal and usually associated with formation of secondary tumors.with formation of secondary tumors.

(Dorland, 1965)

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What is Cancer?What is Cancer?

• __________________________________________________________________• __________________________________________________________________• __________________________________________________________________• __________________________________________________________________• __________________________________________________________________

• ““This knowledge is of significant importance to This knowledge is of significant importance to rehabilitation professionals, as they assist patients to rehabilitation professionals, as they assist patients to realistically identify and achieve goals within their realistically identify and achieve goals within their abilities and prognosis.” abilities and prognosis.”

CDRCDR. . Charles L. McGarvey, M.S., P.T.Charles L. McGarvey, M.S., P.T.

A large group of diseases

Uncontrolled growth

Abnormal cells that lack differentiation

Uncontrolled spread of abnormal cells can result in death

Detected and treated promptly, many types can be cured

(Ward, 1995)

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Normal CellNormal Cell

•Normal DNA•Normal growth•Normal function

nucleolus

nucleus

mitochondrion

centriole

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Cancer CellCancer Cell

•Exhibits uncontrolled growth•Invades surrounding tissue•Destroys healthy tissue•Mutates•Metastasizes•Becomes anaplastic•Has irregular shapes and patterns

•Characteristics:

•Abnormal DNA•Abnormal growth•Abnormal function

1010(Slide permitted by the American Cancer Society)

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Cell CharacteristicsCell Characteristics

• Benign:Benign:– Occasionally largeOccasionally large– Light to dark stainingLight to dark staining– Rare mitotic figuresRare mitotic figures– Round oval nucleusRound oval nucleus– Smooth nuclear edgeSmooth nuclear edge– Nucleus intactNucleus intact– Nucleoli small if presentNucleoli small if present– Multinuclear cellsMultinuclear cells– Clumps of cells similarClumps of cells similar– Focus same windows between Focus same windows between

cells cells

• MalignantMalignant– Many cells may be largeMany cells may be large– Very basophilicVery basophilic– Many mitotic figuresMany mitotic figures– Irregular (bizarre) nucleusIrregular (bizarre) nucleus– Edges indistinct and irregularEdges indistinct and irregular– Nucleus disintegrated edges Nucleus disintegrated edges – Large and prominentLarge and prominent– Vary in size and shapesVary in size and shapes– Clumps vary in sizeClumps vary in size– 3-D must focus up and down 3-D must focus up and down

to see cells; dark staining to see cells; dark staining borders, no windowsborders, no windows

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Tissue Tissue EvaluationEvaluation

• Cell staining: Cell staining:

• Cell cultures: Cell cultures: .

Ability to dye parts of cells to make them

clearer to inspect.

Model for studying active cells in the whole

organism or in vivo.

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•Biopsy:

–Fine-needle aspiration:

–Cutting needle biopsy:

–Incisional biopsy:

–Excisional biopsy:

Suction from syringe to

gather clumps of cells from a tumor.

Obtain small core of tissue

Surgical removal of small area of tissue.

Surgically remove entire tumor for

analysis.

(Altman, 1992)

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Tumor NomenclatureTumor Nomenclature

• Anatomic site of primary tumor (Lung, colon, breast).

• Classification of the tissue of origin (Epithelium, connective tissue)

• Extent of tumor progression (Degree of invasion or metastasis)

• Degree of cell anaplasia (Benign or malignant)

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TumorTumor - - Localized swelling or massLocalized swelling or mass

• Benign: Benign: – Tumors can compress, invade and destroy

adjacent normal tissue; do not invade other tissue and generally not a danger to life.

• Malignant: Malignant: – Endanger life. Can choke out normal tissue, and

spread to other parts of the body (Metastases) through the blood and lymph systems.

(Dollinger et al, 2002)

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Cell DisordersCell Disorders

• HyperplasiaHyperplasia • DysplasiaDysplasia

• MetaplasiaMetaplasia

• AnaplasiaAnaplasia

• An increase in the number of cells of a tissue or organ without tumor formation.

• A cell variation in size and shape from normal. More severe than hyperplasia.

• Unusual cell growth. Differentiated tissue from one kind into another.

• Most serious growth. Absence of normal cellular differentiation in tissue. Cells divide at an increased rate compared to normal cells. Found in most malignancies.

(Otto, 2004)

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CarcinomaCarcinoma• Develops in the lining and covering tissues of Develops in the lining and covering tissues of

organsorgans• 85 – 90% of all Cancers are generally found in

organs that secrete– Examples: Lungs secrete mucus, breast secretes milk,

pancreas secretes digestive juices

Carcinoma in situ: Earliest stage of cancer, with the tumor confined to a local area.

Sarcomas account for 2% of breast cancer. This is a solid tumor that originates in connective

tissue, bone, muscle, cartilage or fat.

:

(Love, 1990)

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Where breast cancer can Where breast cancer can develop:develop:

• Milk ductsMilk ducts• Between ducts Between ducts • In fatIn fat• In lymphatic systemIn lymphatic system• Blood vesselsBlood vessels• NippleNipple• Lobes where milk is producedLobes where milk is produced

(Lang, 2005)

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80% of breast cancers are invasive ductal 80% of breast cancers are invasive ductal carcinoma. Pathologic classifications of carcinoma. Pathologic classifications of less common types of breast cancer:less common types of breast cancer:

•DuctalDuctal– Inflammatory: Inflammatory:

Blockage of the lymph Blockage of the lymph drainage from skin on the drainage from skin on the breast. Red, swollen, thick breast. Red, swollen, thick and pitted.and pitted.

– Medullary: Medullary: Invasive, well defined Invasive, well defined division of cancer and non-division of cancer and non-cancer tissue. Large Ca cells cancer tissue. Large Ca cells and immune system cells and immune system cells around the tumor border.around the tumor border.

– Mucinous: Mucinous: Invasive cancer cells Invasive cancer cells produce mucus and grows produce mucus and grows into a jelly-like tumor.into a jelly-like tumor.

• LobularLobular– Paget’s disease: Paget’s disease:

Affects nipple and areola. Starts in Affects nipple and areola. Starts in milk duct as either in situ or milk duct as either in situ or invasive cancer. Good prognosis.invasive cancer. Good prognosis.

(Jennings-Dozier et al, 2002)

Signs of cancer and risk factors

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7 Warning Signs of Cancer7 Warning Signs of Cancer

• CC change in bowel or bladder habitschange in bowel or bladder habits

• AA a sore that does not heala sore that does not heal

• UU unusual bleeding or dischargeunusual bleeding or discharge

• TT thickening or lump in breast or thickening or lump in breast or elsewhereelsewhere

• II indigestion or difficulty swallowingindigestion or difficulty swallowing

• OO obvious change in a wart or moleobvious change in a wart or mole

• NN nagging cough or hoarsenessnagging cough or hoarseness

(Dollinger, 2002)

Additional Warning Signs Additional Warning Signs Specific to Breast CancerSpecific to Breast Cancer

Breast discharge or bleedingBreast discharge or bleeding

Change in shape of breast or nippleChange in shape of breast or nipple

Tender lymph nodesTender lymph nodes

Skin dimplingSkin dimpling

Noted rash or veins of the breastNoted rash or veins of the breast

(Dollinger, 2002)

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Risk Factors for Breast CancerRisk Factors for Breast Cancer

• Family history (less Family history (less than 7% of breast than 7% of breast cancers are cancers are thought to be thought to be hereditary).hereditary).

• Long menstrual Long menstrual cycles or early cycles or early menarchemenarche

• Late menopauseLate menopause

• First pregnancy First pregnancy after age 30.after age 30.

• Higher education or Higher education or socioeconomic classsocioeconomic class

• StressStress

• ObesityObesity

• Living in Northern Living in Northern U.S.U.S.

• History of colon or History of colon or other female other female cancers.cancers.

(Dollinger, 2002)

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Differential Diagnosis: Before you Differential Diagnosis: Before you treat, make sure the diagnosis is treat, make sure the diagnosis is correct. correct.

• Differential diagnosis is the method by which a clinician considers the Differential diagnosis is the method by which a clinician considers the possible causes of a patient’s clinical findings before making a final diagnosis.possible causes of a patient’s clinical findings before making a final diagnosis.

• Patient with diagnosis of breast cancer:Patient with diagnosis of breast cancer:– Breast, lung and prostate carcinomas.Breast, lung and prostate carcinomas.– Be aware of any history of malignancy.Be aware of any history of malignancy.– ““Lymphedema is an important differential diagnosis in limb swelling”Lymphedema is an important differential diagnosis in limb swelling”

(Tiwari, 2003)

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•THINK……. LOOK FOR CANCER SIGNS

Breast Cancer DiagnosisBreast Cancer Diagnosis

Early detection is optimalEarly detection is optimal

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Methods to Diagnose Methods to Diagnose Breast CancerBreast Cancer

• History & PhysicalHistory & Physical

• BiopsyBiopsy

• Fine Needle Fine Needle AspirationAspiration

• Core Needle BiopsyCore Needle Biopsy

• Surgical BiopsySurgical Biopsy

• MammogramMammogram

• MRIMRI

• CT scanCT scan

• UltrasoundUltrasound

• Bone scanBone scan

• PET ScanPET Scan

• Tumor testsTumor tests

(Altman, 1992)

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Diagnostic tools explainedDiagnostic tools explained

• Biopsies:Biopsies:• Fine Needle Aspiration – Removes cells through a thin hypodermic needle Fine Needle Aspiration – Removes cells through a thin hypodermic needle

connected to syringe and moved in and out of tumor to acquire tissue for connected to syringe and moved in and out of tumor to acquire tissue for evaluation. Fluid is evaluated by a cytologist. This method used for a evaluation. Fluid is evaluated by a cytologist. This method used for a palpated lump, if negative further biopsies needed. palpated lump, if negative further biopsies needed.

• Core Needle Biopsy – A large needle which can yield a tissue sample. Core Needle Biopsy – A large needle which can yield a tissue sample. Needle insertion can be guided by ultrasound or a MRI scanner, which is Needle insertion can be guided by ultrasound or a MRI scanner, which is called image-guided. This tissue study is completed by a pathologist.called image-guided. This tissue study is completed by a pathologist.

• Open biopsies are often prescribed to double check or rule out cancer.Open biopsies are often prescribed to double check or rule out cancer.• Incisional biopsies remove tissue samples through a small incision, enough Incisional biopsies remove tissue samples through a small incision, enough

tissue for pathologist to confirm his conclusion.tissue for pathologist to confirm his conclusion.• Excisional biopsies remove the entire lump and some healthy tissue Excisional biopsies remove the entire lump and some healthy tissue

surrounding the lump. surrounding the lump.

(Braddock, 2002)

2929(Dixon, 2006)

Diagnosis continuesDiagnosis continues• Mammogram is a technique completed routinely for early detection, This is completed by Mammogram is a technique completed routinely for early detection, This is completed by

compressing the breast and obtaining an oblique and a craniocaudal view. Good procedure to compressing the breast and obtaining an oblique and a craniocaudal view. Good procedure to spot lumps to small to be felt. Patterns of interspersed cords of cancer cells among the breast spot lumps to small to be felt. Patterns of interspersed cords of cancer cells among the breast tissue make diagnosis and detection difficult.tissue make diagnosis and detection difficult.

• Magnetic resonance imaging (MRI) Combination of magnetic and radio waves that are a high Magnetic resonance imaging (MRI) Combination of magnetic and radio waves that are a high sensitivity device which can show the extent of the invasive or non-invasive disease. This sensitivity device which can show the extent of the invasive or non-invasive disease. This procedure is completed by showing blood vessels in tissue. This tool is valuable for high risk procedure is completed by showing blood vessels in tissue. This tool is valuable for high risk females as well as following neoadjuvant therapy.females as well as following neoadjuvant therapy.

• CAT scan is computer aided to create a three dimensional images of organs and structures CAT scan is computer aided to create a three dimensional images of organs and structures for further specific diagnosis, if needed.for further specific diagnosis, if needed.

• Ultrasound is a high frequency sound wave beamed through breast tissue and reflections are Ultrasound is a high frequency sound wave beamed through breast tissue and reflections are detected and turned into images. Cancer cells usually have a distinct outline compared to detected and turned into images. Cancer cells usually have a distinct outline compared to normal cells. The results of this examination are operator dependent. normal cells. The results of this examination are operator dependent.

• Bone scan detects increased blood circulation in a bone, which could reveal metastases.Bone scan detects increased blood circulation in a bone, which could reveal metastases.• Pet Scan (Positron emission tomography) similar to X-ray except Pet scans show cell activity, Pet Scan (Positron emission tomography) similar to X-ray except Pet scans show cell activity,

by detecting the rate cells consume glucose. Cancer cells use up sugar faster than normal by detecting the rate cells consume glucose. Cancer cells use up sugar faster than normal cells. cells.

• Tumor testing can be completed by using estrogen and progesterone receptors as Tumor testing can be completed by using estrogen and progesterone receptors as well as other genetic measurements.well as other genetic measurements.

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MammographyMammography

Radiologist read the test results and compare Radiologist read the test results and compare them to previous mammograms when possible.them to previous mammograms when possible.

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Non-palpable intraductal Non-palpable intraductal carcinomacarcinoma

Mammogram

(Slide permitted by the American Cancer Society)

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Medullary carcinoma: Thought benign Medullary carcinoma: Thought benign but mammogram and but mammogram and biopsy=suspicion of CAbiopsy=suspicion of CA

(Slide permitted by the American Cancer Society)

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Female Protection Against CancerFemale Protection Against Cancer

• BREAST - Monthly breast self-exam between Age 20-40 Health professional breast check /3yrs

• Age 40 - 1st mammogram• Age 40-50 - Health professional breast check/yr; mammogram every 1-2 yrs.

• Over 50 = Health professional and annual mammogram

SEE HEALTH CARE PROVIDER WITH ANY CHANGES IN BREAST

(Jennings-Dozier et al, 2002)

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Male breast cancerMale breast cancer

• < 1% of breast cancer< 1% of breast cancer• 1500 new cases and 400 fatalities/year 1500 new cases and 400 fatalities/year

(Compared to 203,500 new cases in (Compared to 203,500 new cases in women)women)

• Risk increases with family history of Risk increases with family history of mutated BRAC2mutated BRAC2

• Prognosis similar to female, testing size, Prognosis similar to female, testing size, grade and nodes.grade and nodes.

• Treatment with mastectomy and other Treatment with mastectomy and other interventions as prescribed by oncologist. interventions as prescribed by oncologist.

(Donegan, 2002)

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PATHOLOGY AND TUMOR

STAGING

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Specific StagingSpecific Staging

• To no palpable tumorTo no palpable tumor• Tis cancer in situTis cancer in situ• T1 < 2 cm T1a <0.5 cmT1 < 2 cm T1a <0.5 cm• T1b >0.5 – 1 cmT1b >0.5 – 1 cm• T1c >1-2 cmT1c >1-2 cm• T2 > 2-5 cmT2 > 2-5 cm• T3 > 5 cmT3 > 5 cm• T4a involved chest wallT4a involved chest wall• T4b involved skinT4b involved skin• T4c T4a and T4b togetherT4c T4a and T4b together• T4d inflammatoryT4d inflammatory• No no regional node metastasisNo no regional node metastasis• N1 palpate morbile ipsilateral axillary nodes involvedN1 palpate morbile ipsilateral axillary nodes involved• N2 fixed ipsilateral axillary nodes N2 fixed ipsilateral axillary nodes • N3 ipsilateral internal mammary lymph node metastasis N3 ipsilateral internal mammary lymph node metastasis • Mo no distant metastasisMo no distant metastasis• M1 distant metastasisM1 distant metastasis

(Dixon, 2006)

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Classification leads to StageClassification leads to Stage

• Stage 0 Stage 0 – Lobular carcinoma in situ (LCIS) abnormal Lobular carcinoma in situ (LCIS) abnormal

cells lining a gland in the breast.cells lining a gland in the breast.– Ductal carcinoma in situ (DCIS) abnormal cells Ductal carcinoma in situ (DCIS) abnormal cells

lining a duct; has risk of becoming invasive. lining a duct; has risk of becoming invasive.

Continue

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Diagnostic Staging Diagnostic Staging (TNM classification)(TNM classification)

Stage 1Stage 1 Stage 2Stage 2 Stage 3Stage 3 Stage 4Stage 4

TumorTumor 0-2 cm0-2 cm 2-5 cm2-5 cm Any sizeAny size Any sizeAny size

NodesNodes Negative Negative Negative or Negative or PositivePositive

LargeLarge

Near clavicleNear clavicleAny nodesAny nodes

METSMETS No metastasisNo metastasis No metastasisNo metastasis No metastasisNo metastasis MetastasisMetastasis

(Abraham, 2005)

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• C TNM pre-op clinical diagnosis• P TNM post-surgical resection pathology• R TNM re-treatment staging--recurrence• A TNM autopsy

(Otto, 2004)

4040(Slide permitted by the American Cancer Society)

Note decrease survival with increase stage

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Time Out Test Time Out Test

• What was the expected total number of What was the expected total number of breast cancer expected in 2005?breast cancer expected in 2005?

• Name the abnormal activities of cancer Name the abnormal activities of cancer cells.cells.

• Removing cells and tissue for diagnosis is?Removing cells and tissue for diagnosis is?

• Once metastasis occurs what tumor grade is Once metastasis occurs what tumor grade is recorded?recorded?

• Doubling refers to cancer growth? T/FDoubling refers to cancer growth? T/F

• Carcinoma is a solid tumor? T/FCarcinoma is a solid tumor? T/F

Answers:274,900 diagnosed; abnormal DNA, growth and function; biopsy; Grade 4;True; False (Sarcoma is a solid tumor).