What is Breast Cancer ? Abnormal cells develop from normal cells in the breast to form tumors Abnormal cells develop from normal cells in the breast to form tumors Tumor cells have genetic defects that allow the cells to grow too rapidly and to invade normal tissues Tumor cells have genetic defects that allow the cells to grow too rapidly and to invade normal tissues Normal cells Malignant cells

Breast Cancer: Statistics Breast cancer is the most common cancer in American women 20% of all cancers in women Commonest cause of death y 185,000 new cases every year breast cancer Lifetime risk for the average woman; approximately one in nine will develop breast cancer

Risks Finding of pre-malignant changes in breast tissue Finding of pre-malignant changes in breast tissue Never having children Never having children Having first child after age 30 Having first child after age 30 Obesity - Alcohol - Estrogen therapy Obesity - Alcohol - Estrogen therapy

What is the risk for developing breast cancer? Age years Age years History of breast cancer in a close relative (mother/sister/daughter) History of breast cancer in a close relative (mother/sister/daughter) 90% of women with breast cancer have no relatives with the disease 90% of women with breast cancer have no relatives with the disease

Stages of breast cancer The rate at which a cancer will grow is not predictable - some tumors grow slowly, others rapidly The rate at which a cancer will grow is not predictable - some tumors grow slowly, others rapidly The earlier a tumor is identified, the better the chance for cure The earlier a tumor is identified, the better the chance for cure 95% of women with cancers less than 1/2 inch in size are cured 95% of women with cancers less than 1/2 inch in size are cured Advanced cases are fare from cure our aim is palliation Advanced cases are fare from cure our aim is palliation

Spread of Breast Carcinoma: Direct Lymphatic Blood

TNM Staging Tx primary tumor can not be assessed Tx primary tumor can not be assessed Tis In situ carcinoma & paget’s disease Tis In situ carcinoma & paget’s disease T0 no palpable mass T0 no palpable mass T1 tumor < or = 2 cm T1 tumor < or = 2 cm T1a < or = 0.5 cm no deep fixation T1a < or = 0.5 cm no deep fixation T2b 0.5 – 1 cm + deep fixation T2b 0.5 – 1 cm + deep fixation T3c 1 – 2 cm + deep fixation T3c 1 – 2 cm + deep fixation T2 tumor 2 – 5 cm T2 tumor 2 – 5 cm T2a no deep fixation T2a no deep fixation T2b deep fixation T2b deep fixation T3 tumor 5 – 10 cm T3 tumor 5 – 10 cm T3a no deep fixation T3a no deep fixation T3b deep fixation T3b deep fixation T4 tumor of any size T4 tumor of any size T4a direct chest extension T4a direct chest extension T4b skin ( Peau d’orange, skin nodule & ulceration) T4b skin ( Peau d’orange, skin nodule & ulceration) T4c T 4a + T4b T4c T 4a + T4b T4d inflammatory breast cnacer T4d inflammatory breast cnacer Tumor

TNM Staging N x can not be assessed N x can not be assessed N 0 not palpable LN N 0 not palpable LN N 1 palpable homo-lateral axillary LN and mobile N 1 palpable homo-lateral axillary LN and mobile N 2 palpable homo-lateral axillary LN and fixed N 2 palpable homo-lateral axillary LN and fixed N 3 ipsilateral internal mammary LN N 3 ipsilateral internal mammary LN M X can not be assessed M X can not be assessed M 0 no known metastases M 0 no known metastases M 1 distant metastases including supra-clavicular LN M 1 distant metastases including supra-clavicular LN Nodes Metastases

St ag Definition 5-year Surv (%) 7-year Surv (%) ITumor 2 cm or less without spread9692 II Tumor 2-5cm with regional lymph node involvement but without distant metastases, OR > 5 cm in diameter without spread 8171 III Any size with skin/chest wall fixation, & axillary or internal mammary nodal involvement, without distant metastases 5239 IV Tumor of any size with or without regional spread but with evidence of distant metastases 1811

What is the best defense against breast cancer? Be aware of personal risk for breast cancer Be aware of personal risk for breast cancer Practice monthly breast self exam Practice monthly breast self exam Have a screening mammogram every year once the female are 40 years old Have a screening mammogram every year once the female are 40 years old Have an annual breast exam every year after age 40 Have an annual breast exam every year after age 40 See doctor promptly if the patient note a new breast lump or thickening See doctor promptly if the patient note a new breast lump or thickening Enjoy a healthy life: control weight, minimize alcohol, don’t smoke, exercise Enjoy a healthy life: control weight, minimize alcohol, don’t smoke, exercise EARLY DETECTION

Breast self examination for early detection EARLY DETECTION LEADS TO CURE

What if a female feel a lump in her breast? The patient should go to her doctor immediately for a physical examination; and don’t wait for annual examination The patient should go to her doctor immediately for a physical examination; and don’t wait for annual examination The doctor may refer the patient for breast imaging - a mammogram The doctor may refer the patient for breast imaging - a mammogram A biopsy may be recommended, depending on the features of the lump A biopsy may be recommended, depending on the features of the lump Many lumps in the breast are NOT cancer; benign fibrocystic disease and benign tumors are common Many lumps in the breast are NOT cancer; benign fibrocystic disease and benign tumors are common EARLY DETECTION LEADS TO CURE

Mammography Mammograms are sensitive x rays of the breast Mammograms are sensitive x rays of the breast Small, safe dose of radiation is used Small, safe dose of radiation is used Minor discomfort due to pressure on the breast is noted by some women Minor discomfort due to pressure on the breast is noted by some women EARLY DETECTION LEADS TO CURE

Mammography Mammograms can detect premalignant changes Mammograms can detect premalignant changes Mammograms are the best means to find early curable cancers - cancers too small to be detected by touch Mammograms are the best means to find early curable cancers - cancers too small to be detected by touch 85% of cancers will show up on a mammogram - 15% will not 85% of cancers will show up on a mammogram - 15% will not EARLY DETECTION LEADS TO CURE

Two Methods of Mammograms Ordinary film Ordinary film Xero or zeno mammography Xero or zeno mammography over selinium plates gave different colors blue and whiteover selinium plates gave different colors blue and white EARLY DETECTION LEADS TO CURE

Abnormal Mammographic findings Satellite lesion lesion Micro calcifications Linearbranching Roundedpunctuate Circumscribedlesion Speculatedlesion Mammographic signs of malignancy 1.Breast lump 2.Linear or branching micrcalcification 3.Skin or nipple thickening 4.Mammary duct distortion or asymmetry

What if abnormal mammogram? The patient seek medical advice for a breast examination The patient seek medical advice for a breast examination Special mammogram will be done to confirm if the finding is real Special mammogram will be done to confirm if the finding is real Additional imaging tests - ultrasound - for better definition Additional imaging tests - ultrasound - for better definition Close follow-up imaging may be recommended at 6 months or: Close follow-up imaging may be recommended at 6 months or:

What if abnormal mammogram? Biopsy may be recommended Biopsy may be recommended Needle biopsy - Ultrasound directedNeedle biopsy - Ultrasound directed Needle biopsy - mammogram directedNeedle biopsy - mammogram directed Surgical biopsySurgical biopsy The tissue diagnosis is the most important information in planning treatment The tissue diagnosis is the most important information in planning treatment Most mammogram abnormalities are not cancer; most are due to benign changes Most mammogram abnormalities are not cancer; most are due to benign changes

How is the diagnosis of breast cancer made? A suspicious sign on a mammogram or a lump in the breast will indicate the need for a tissue biopsy A suspicious sign on a mammogram or a lump in the breast will indicate the need for a tissue biopsy A biopsy of the abnormal tissue is required to make the diagnosis of breast cancer A biopsy of the abnormal tissue is required to make the diagnosis of breast cancer A careful physical examination will give signs about the stage of the cancer A careful physical examination will give signs about the stage of the cancer size of tumor in breastsize of tumor in breast lymph node enlargement under armlymph node enlargement under arm status of the opposite breaststatus of the opposite breast

How is the diagnosis of breast cancer made? Features of the tumor: Features of the tumor: Type of breast cancer - ductal, lobular, etcType of breast cancer - ductal, lobular, etc Grade of the tumorGrade of the tumor Hormone receptor statusHormone receptor status Indicators of biologic growth rate potentialIndicators of biologic growth rate potential c-erbc-erb

Can breast cancer be prevented? Recent studies showed that women with an increased risk for breast cancer can have that risk decreased by % by taking the anti-estrogen medication tamoxifen Recent studies showed that women with an increased risk for breast cancer can have that risk decreased by % by taking the anti-estrogen medication tamoxifen Tamoxifen benefited women with: Tamoxifen benefited women with: the breast cancer genethe breast cancer gene age greater than 55 yearsage greater than 55 years premalignant changes in previous biopsiespremalignant changes in previous biopsies Side effects Side effects very small increase in risk of cancer of the uterusvery small increase in risk of cancer of the uterus blood clotsblood clots

How is breast cancer treated? 1. SURGERY: to remove all the tumor Breast preserving surgery - most patientsBreast preserving surgery - most patients Removal of the full breast - mastectomy - may be required for some patientsRemoval of the full breast - mastectomy - may be required for some patients 2. DETERMINE THE STAGE OF THE TUMOR: Remove some of the lymph nodes under the arm to look for tumor metastases

How is breast cancer treated? 3. ADJUVANT THERAPY: Medical therapy to decrease the chance of tumor recurrence - to improve the chances for cure Chemotherapy - many different therapies Chemotherapy - many different therapies Hormonal therapy - tamoxifen, aromatase inhibitors Hormonal therapy - tamoxifen, aromatase inhibitors

How is breast cancer treated? 4- RADIATION THERAPY - to prevent tumor recurrence in the remaining breast tissue; required for breast preserving therapy