Overview: Breast Cancer- Surgical Treatment Ms S Tormey Consultant Breast Surgeon MWRH Dooradoyle Limerick Slainte an Chlair Meeting, Ennis June 2011

Statistics 1 in 9 women Rising incidence 2010 > 2,500 cancers diagnosed in Ireland Outcome from breast cancer has improved

HISTORICAL PERSPECTIVE Ancient Eygptians 3,500 Hippocrates 460 BC- humoral disease Breast Cancer considered systemic- surgery did not cure because this was a disease involving the entire body (Humoral Theory)

Move to Localised Theory 17th Century- Localised disease potentially curable with surgery 19th Century-Halstead-Era of Radical Mastectomy

Anatomy Halstedian theory Cancer spread anatomically Breast- Lymphatics/ direct invasion of surrounding tissues

Oncology Development 1895 Beatson- oopherectomy 1896 Emile Grubb- radiotherapy Chemotherapy- 20th century

Influential Clinical Trials NSABP Milan Breast Conservation and radiotherapy Chemotherapy development and trials

Modern Surgical Practice Less invasive surgery More attention to cosmetic outcomes Improved prognosis

Oncological Approach Combining treatments: Surgery/Chemotherapy/Radiotherapy/Biological treatments Multidisciplinary “Tailored” approach

Breast Cancer Services in Ireland Specialist Cancer Centres Population of 250,000-300,000 per centre 100 -150 new cancers p.a. per centre High volume of cancer cases leads to experienced personnel National Quality Assurance Standards for Symptomatic Breast Disease Services (Ireland 2000)

National Cancer Control Programme Established 2006 Cancer Strategy 8 Cancer Centres West: GUH and Limerick South:CUH and Waterford East:Mater/Vincents, Beaumont and James’

Minimally invasive surgery 1970 Breast conservation 1990’s Sentinel node biopsy

Breast Conservation/Oncoplastic Surgery Volume reduction Scars Symmetry .

Oncoplastic/Reconstructive Surgery In past decade- evolving speciality Preservation of the breast with a cosmetic appearance, after oncological resection (oncoplastic resection) or reconstruction after mastectomy- either immediate or delayed

Neoadjuvant Chemotherapy Pre-op Chemotherapy NAC may convert a tumour from a unifocal entity to a multifocal entity Following neoadjuvant therapy, it is possible to have a cPR, a pPR or no response. Negative Margins Negative Margins Positive Margins

Reconstruction Skin sparing immediate Nipple sparing- immediate

Who? Multidiciplinary discussion Factors influencing: Breast size Tumour size Pathology Age Prerequisite before decisions: Triple assessment and diagnosis

Triple Assessment Triple assessment- gold standard Clinical, Radiology, Pathology

Clinical Assessment History and Examination Clinical diagnosis Accuracy- clinical breast examination is reported to have sensitivity of 68-80%

Radiological Assessment Mammography Ultrasound- focal palpable area on clinical assessment/focal area of pain

Mammography Standard screening tool for breast Sensitivity increases with age Overall sensitivity 75%, but 54-58% < 40years, and 81-94%> 65 yrs YOUNG WOMAN POST MENOPAUSAL WOMAN

Ultrasound Used to evaluate focal areas in breast- palpable lumps/painful areas, or an area seen on mammography Low sensitivity and specificity when used for screening

Ultrasound Guided core biopsy Increases accuracy Current standard for performing breast biopsy in lesions graded U3 or above

Same Day Service TAC visit takes 2-3 hours to complete Results from imaging available at the end of the visit Re visit the primary clinician for results Second visit necessary for biopsy results

Multidisciplinary Meeting Consists of symptomatic breast unit core personnel ie surgeons, radiologist, pathologist, medical oncologist, radiation oncologist, breast care nurses, radiographers Held weekly All imaging, and clinical assessment re visited, and biopsy results Consensual decision re outcome All surgically excised breast cancer discussed- decisions son treatment

Summary Last 25 years- many large trials have led to better outcomes Current research- focus on understanding cancer genes and cancer cell growth to achieve potentially more targeted “individualised” treatment