Recent and evolving trends in breast and colon cancer by Jeff Kolbasnik

Breast cancer -Should we screen for breast cancer? - Yes, but... - Investigation of breast complaints: - assessment of risk - breast lump, pain, nipple discharge - mammography, U/S, MRI

Incidence and prognosis - drop in incidence 10 yrs ago with decreasing use of HRT - incidence now increasing (50% over 25 yrs) - but prognosis much improved (ER+) - improvements in prognosis due to adjuvant therapy (chemo and endocrine) - fewer patients dying of breast cancer, but more living with consequences of treatment

BiRADS classification - for mammography and U/S - level of suspicion for malignancy - biopsy all BiRADS 5 and most BiRADS 4

Role of Surgery - usually first step in management (except for advanced cancers) - local control with lumpectomy/mastectomy - possible local control with axillary dissection, but more commonly for prognosis and adjuvant therapy planning

Oncoplastic surgery, immediate reconstruction - availability, waiting time - proper patient selection - caution when adjuvant chemotherapy likely - role of multi-disciplinary cancer conferences

Management of the axilla - axillary dissection to sentinel node biopsy - Z0011 trial; no “completion” dissections - extrapolated to other patient populations - used to plan adjuvant therapy - FNA may be sufficient

Pre-op investigations - mammography and U/S (include axilla) - ? MRI - limited to no role for metastatic work-up - percutaneous biopsy

- endocrine therapy for ER+ tumours - herceptin for Her-2-neu positive tumours

Surveillance - mammography; ?MRI; no U/S - functional/quality of life status

DCIS vs. LCIS - surgery +/- radiation for DCIS - routine screening for LCIS

Colon Cancer - differentiate screening from investigations - FOBT is a screening test only! - no need for FOBT following negative colonoscopy - appropriate surveillance intervals for adenomatous polyps, other findings (choose your endoscopist wisely)

Investigations - many colon cancers are asymptomatic - worrisome: microcytic anemia, obstructive symptoms, GI symptoms with weight loss - possibly worrisome: rectal bleeding, elderly patient with change in bowel habits - functional complaints common - consider risk profile - endoscopic and abdo imaging

Screening options - metabolic testing/DNA testing - fecal tests - endoscopic tests - radiological tests

Transition from FOBT to FIT - more accurate test, though must set benchmark - easier to perform - fewer false positives and false negatives - more significant polyps at colonoscopy

Consider: - test accuracy/false negative rates - complication rates - patient compliance / patient preference - access, follow up

System must consider: - participation rates - colon cancer incidence reduction rates - cost and cost effectiveness

Colon cancer management - polypectomy for malignant polyps - rare transanal approaches - laparoscopic and open resections - surgery usually first step; may need neoadjuvant chemotherapy/radiation for rectal cancer - adjuvant therapy usually well tolerated - metastatic disease often treatable

Surveillance - colonoscopy for recurrence and new polyps - liver/chest imaging for mets - CEA