Breast Cancer Anne Kelly RN,MS,NP-C AOCNP October 25,2017

Disclosures None

Outline Epidemiology Risk Factors Screening Diagnosis Treatment Genetic testing Research

Epidemiology 2017 :estimated 252.710 new cases of invasive breast cancer in women Additional 2470 cases of breast cancer in Men Most common cancer among women 1/8 women (12%) will develop invasive breast cancer in there life time 40,610 death from breast cancer in 2017 This is 16% of patient diagnoses (population risk from breast cancer related death among women is about 3%) 2nd leading cause of cancer death in women ( Lung Cancer is 1 st) Death rates have been declining since 1989 More than 2.8 million breast cancer survivors

Non-Modifiable Risk Factors Gender Age Personal History Early Menopause Race /Ethnicity Dense Breast Tissue LCIS Family History Genetic History Late Menopause Exposure to Chest Radiation before age 30

Modifiable Risk Factors Hormone replacement Late first full-term pregnancy Oral contraceptives Obesity after menopause Nulliparity Alcohol consumption

Screening for Breast Cancer Mammogram MRI Self Breast exam Clinical breast exam

MAMOGRAM Stanard vs.3 D (tomosynthesis) Screening vs Diagnostic What do we see on Mammogram

NCCN Screening guidelines Average Risk Clinical encounter every 1-3 yrs. Breast awareness Age 40 Clinical encounter yearly Annual Mammogram Clinical encounter+ ongoing risk assessment , risk reduction counseling, and a clinical breast exam

NCCN Screening Guidleines High risk Personal Hx breast cancer >20% life time risk Chest radiation before age 30 Genetic mutation ( family Hx suggestive of mutation)

NCCN Screening Guidleines High risk cont. Clinical encounter every 6-12 months starting at age risk is identified but not earlier than 30 (Chest wall radiation beginning 8-10 yrs after tx ) Annual mammogram ( not earlier than 30) Consider annual MRI ( not before age 25) Breast awareness Consider risk reduction Healthy living Surgery Pregnancy Tamoxifen

Synptoms of Breast Cancer Abnormal mammogram New Lump or Mass Skin or nipple Changes -dimpling, irritation, redness, scaliness, thickening Breast or nipple pain Nipple retraction Nipple bleeding/discharge Lymphadenopathy

Inflammatory Breast Cancer Automatically considered Stage III (skin involvement) 35% are metastatic at diagnosis Usually no single lump or tumor 1-6% of all breast cancers Presents with erythema of breast and peau d’orange Hallmark: dermal lymphatic involvement Poor prognosis Just a quick note about IBC in case you see it in your practice b/c time is of the essence in IBC The propensity for metastatic disease is so high that you have to start with chemotherapy very quickly Approach to treatment: Pre-op chemo, mastectomy, PMRT, endocrine therapy if ER+ American Cancer Society

Diagnosis Diagnostic Mammogram Ultra Sound Biopsy Referral to surgeon and or/Medical oncologist MRI??

American Cancer Society DCIS is a non-invasive or pre-invasive lesion The cells within the ducts have changed, but have not spread or invaded through the walls of the ducts into surrounding breast tissue It has no ability to spread or metastasize outside of the breast if it’s treated properly (which is how it differs from LCIS) Lot of recent controversy lately regarding whether or not we over-treat DCIS American Cancer Society

Types of Breast Cancer Cell type Receptors Non invasive Invasive Lobular Ductal Invasive Inflammatory Estrogen Progesterone Her 2 nu Hormone positive ER + Her 2 nu +- ER/ PR- Her 2 nu + Triple negative

Treatment Decision Making Multiple Factors Tumor Size Nodes involved Tumor Grade Subtype Patient Age Patient other medical problems Oncotype

AJCC Breast Cancer Staging Stage Description 5-Year Survival Rate I ≤ 2 cm, node negative 95-100% IIA 2-5 cm, node negative < 2 cm, node positive 92% IIB > 5 cm, node negative 2-5 cm, node positive 81% IIIA > 5 cm, node positive < 5 cm, node positive with matted lymph nodes 67% IIIB Tumor penetrated to the skin of breast or chest wall or spread to internal mammary nodes 54% IV Distant metastases 20% American Joint Committee on Cancer (AJCC) was established in 1959 to formulate and publish systems of classification of cancer, including staging and end results reporting, which will be acceptable to, and used by, the medical profession for selecting the most effective treatment, determining prognosis, and continuing evaluation of cancer control measures. Comprised of multiple member organizations (ACS, ASCO, CDC, etc.)

Local treatment Surgery Radiation Lumpectomy Mastectomy After Lumpectomy After mastectomy Hypo fractionated

Systematic Treatment Chemotherapy Before surgery (neoadj treatment) Post surgery (adjuvant) Hormonal /Endocrine therapy for Estrogen + disease Tamoxifen Aromatase Inhibitors Endocrine therapy is usually give 5-10 yrs. reduces risk of recurrence by about 50% where as Chemotherapy reduces risk by about 1/3

Advanced Disease Incurable, but treatable; goal is palliative Common sites Liver,Lung, Bone, Brain Skin Treatment approach : sequential single-agent therpaies ER+: endocrine therpay first.unless high tunor burdon/ Very symptomatic Several different chemo agents 4 differnet HER 2 Nu targeted agents available Novel agents/ Clinical trials

Genetic testing Family Hx Breast cancer diagnose at young age BRCA 1 and 2 genes Gene Arrays

Survivorship How do we follow people after diagnosis of breast cancer Nutrition Exercise Sexual Health Potential long tern complication form treatment Fertility Neuropathy Cardiac Dysfunction Lymphedema Secondary Cancers

Research 1987 – Her-2 amplification correlated with poor overall survival 2013 – Tamoxifen x 10 years 1975 – Adjuvant chemo shown to prolong life 1894 – Halsted’s Mastectomy 2004 – Aromatase Inhibitors introduced ?? 2008 – hypo-fractionated radiation = conventional radiation 1940s – OS in pre-menopausal women 1977 – Tamoxifen FDA approved 1993 – SLNB shown to reliably predict axillary status 2015 – Ibrance FDA approved 1977 – Lumpectomy + XRT = Mastectomy

References American Cancer Society https://www.cancer.org/cancer/breast-cancer.html NCCN Guidelines https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast American Society of Clinical Oncology (ASCO) https://www.asco.org/ Oncology Nursing Society https://www.ons.org/

Thank You Any Questions ? Anne Kelly akelly@partners.org