BREAST CANCER Oncology John Dewar

Breast Cancer Commonest cancer in women 2nd commonest cause of death from cancer in women Survival improving – 5 yr. survival improved from 56% 1970 to 79% in 1999 (year of diagnosis) Increasing incidence – ageing population

Presentation Screening – age 50-64(70), small, impalpable Symptomatic – lump in breast 8% with distant metastases 8% locally advanced/inoperable 84% operable

TREATMENT Surgery Radiotherapy Systemic therapy hormonal therapy cytotoxic chemotherapy immunotherapy

RADIOTHERAPY Postoperatively to breast/chest wall nodal areas: axilla, supraclavicular fossa, internal mammary nodes Primary radical for locally advanced Palliatively to painful bony mets, skin deposits, brain mets etc.

POSTOPERATIVE RADIOTHERAPY Reduces the risk of local recurrence by about two thirds: 60% to 20% 30% to 10% 3% to 1%

POSTOPERATIVE RADIOTHERAPY All patients being treated conservatively (wide local excision/lumpectomy) Mastectomy patients selectively – large tumour, extensive nodal involvement, involved margins etc.

Postoperative Radiotherapy – acute side effects Skin erythema to moist desquamation Tiredness Dysphagia if irradiating supraclavicular fossa No alopecia

Postoperative Radiotherapy – late effects Local fibrosis and telangectasia Lung fibrosis (rarely symptomatic) Cardiac damage (ischaemic heart disease) – rarer now treatment better planned

Postoperative Radiotherapy – late effects Survival Overall 5% improvement in breast cancer survival (at 15 yrs.) for 20% improvement in local control (4% improvement in overall survival) Localised local recurrence can act as nidus for distant metastases

SYSTEMIC THERAPY – adjuvant Most operable, why not curable? Occult distant metastases at presentation Systemic therapy after surgery reduces the risk of recurrence and death – adjuvant therapy

SYSTEMIC THERAPY – adjuvant Hormone therapy: ovarian ablation, tamoxifen, aromatase inhibitors (ER/Pg +ve patients only) Cytotoxic chemotherapy: CMF, doxirubicin/epirubicin, taxanes Trastuzumab [Herceptin] All decrease odds of death by about 17%, absolute benefit of about 6% at 10 years.

SYSTEMIC THERAPY – adjuvant: side effects Hormone therapy: Infertility Menopausal symptoms Weight gain Endometrial cancer Deep venous thrombosis Chemotherapy Nausea & vomiting Infertility Alopecia Neutropenia (sepsis) Mouth ulcers Lassitude

METASTATIC DISEASE Incurable but treatable Optimise quality of life and survival Median survival with mets: 2 years (20% at 5 yrs.) Varies from acute aggressive disease to chronic disease (like diabetes, renal failure etc.)

METASTATIC DISEASE Assess extent of disease Stage: local recurrence, lung, liver, bone Hormone receptor status HER2 receptor status

METASTATIC DISEASE Local problems Palliative radiotherapy: bony mets, brain mets etc. Drainage of pleural or peritoneal effusions Pining of pathological fractures

METASTATIC DISEASE Systemic therapy Hormone therapy if ER/Pg +ve Chemotherapy Bisphosphonates for bony mets Trastuzumab if HER2 +ve

METASTATIC DISEASE Systemic therapy ER +ve: Hormonal agents: ovarian ablation, aromatase inhibitors, tamoxifen, progestagens in sequence unless liver mets or lymphangitis carcinomatosa when usually chemotherapy

METASTATIC DISEASE Chemotherapy: CMF, anthracyclines, taxanes, capcitabine etc. etc. Use in sequence so long as respond and patient fit

BREAST CANCER Need multidisciplinary management: nurses, surgeons, radiologists, pathologists, oncologists, GP. etc. etc. Different patients have different needs Most will need considerable support Major impact on the patients but also their families