Breast Cancer, A Common Problem in Sri Lanka Dr Dehan Gunasekera Consultant Oncologist National Cancer Institute of Sri Lanka

Leading Cancer sites-2010 Male Lip ,oral cavity and pharynx 14.1 % Bronchus and Lung 7.7 % Oesophagus 5.8 % Colon rectum 4.4 % Female Breast 18.4 % Cervix 8.9 % Ovary 5.9 % Thyroid 5.6 %

5012 new Cancer patients 6063 new Cancer patients 7300 new Cancer patients 10925 new Cancer patients 12632 new Cancer patients 13372 new Cancer Patients

Breast Cancer Epidemic! Asian-young,ER-,PR-,High grade Europian->50 years,ER+,PR+ Awareness of Breast CA at all ages Presentation Mammographic detection Blood stained nipple discharge Self detected lump Clinical breast examination detected Locally advanced-ulcer,Peud’orange Metastatic-Pleural effusion,Back ache

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Diagnosis Triple assesment Clinical Examination-site,size for staging Mammogram/US scan in < 40-45 years FNAC/Core(trucut) biopsy Metastatic Survey General and systemic examination Xray chest US scan Abdomen and Pelvis LFT FBC,SC Bone Scan,CT scan–depending on the symptom

Histology Preinvasive CA Duct Carcinoma in Situ (DCIS) Lobuler Carcinoma in Situ (LCIS) Invasive CA Duct CA Mucinous Ca Medullary CA Papillary CA Lobuler CA

Receptor status is mandatory General Concept ER-,PR- Poor prognosis Her2- Good prognosis Change in Concepts due to Complicated cross talk between Receptors Concept of Triple negative Disease ER (-) PR (-) Her-2/neu (-)

Treatment Early Stage –Surgery Breast Conserving Surgery+RT to the breast Wide local Excission Qadrantectomy Lumpectomy Mastectomy+immediate or delayed reconstruction Axilla- US scan axilla (-) LN –Sentinal Lymph node biopsy US scan axilla (+) LN- Axillary clearance

Place for Radiotherapy Mandatory in Breast conservation Lymph nodes in Axilla+ Large tumours (>5 cm) Poorly Differentiated CA To relieve pain locally-spine Place of Chemotherapy Post operative(Adjuvant) ER-,PR-,Her2 + Metastatic Disease

Preoperative(Neoajuvant) Locally advanced disease(T3,T4) Inoperable Chemothrapy-Anthracyclin based Paclitaxel based Place of hormonal Therapy ER+,PR+ Premenapausal-Tamoxifen ER+,PR+ Postmenapausal- Aromatase inhibitors Anastrazole Letrazole Exemestane

The occurrence of relapse and survival (Prognosis) are influenced by 1.Stage at presentation (Size,Pathology,Grade,Metastasis) 2.Lymph node status 3.Hormone receptor status 4.Measures of proliferation of the cancer cell 5.Genetics of the cancer and the host 6.Age at diagnosis

St Galens Recommendations Low risk T1 N0 G1 ER+ and /or PR+ Her2 – >35 years No lymphovasculer invasion

Intermediate risk ER and/or PR + Her2 – N0 No lymphovasculer invasion pT>1 or G2-3 or <35 years or (1-3) LN

High risk ER- and PR- LN >3 Her2+ or LN 1-3 with lymphovasculer invasion

Stage 5 year survival Stage I T1 NO M0 85% Stage II T0-1 N1 M0 T2 N0-1 M0 65% T3 N0 M0 Stage III T0-2 N2 M0 T3 N1-2 M0 T4 any N M0 45% Any T N3 M0 Stage IV Any T any N M1 10%

Prevention All females should do self breast examination monthly Women over 40 years old should have Clinical breast examination every 3 years Bilateral Mammogram at perimenapausal age of 45-50 years If Clinical Breast examination detects a suspicious lesion under the age of 45 years-US scan breasts and ideally MRI of Breast

Thank you