1. Elizabeth Murray Clinical and Radiation Oncology

2. Margin Probe

3. Endomagnetics

5. APBI: POSTOP – INTERSTITIAL BRACHTHERAPY

6. 16 vs 25

7. ASTRO GUIDELINE FOR WHOLE BREAST HYPOFRACTIONATION Age >/=50 pT1-2 No CT Good homogeneity (7% CA plane/size issue) 42.5Gy in 16 Exclude heart from primary treatment field Boost???? Not necessarily contraindicated in others, task force not in agreement

8. APBI: POSTOP – INTERSTITIAL BRACHTHERAPY

9. APBI: POSTOP – INTERSTITIAL BRACHYTHERAPY

10. RISK

11. Can I Modify My Patient’s Breast Cancer Risk ? 1.Yes 2.No 3.Sometimes 4.Don’t know

12. Risk Management and Surveillance

13. What Are Breast Cancer Risk Factors?

14. Risk Factors Female Older age (>50) Family history Overweight (postmenopausal) All women: Maintain BMI18.5-25 kg/m² Alcohol (Add folic acid if drink alcohol) Smoking

15. Risk Factors cont’d HRT and OC Nulliparity or first child over 30 Probably red meat / animal fats Reduce risk with: o Vigorous exercise o Breast feeding ≥ 6/12 o ?Vit D and calcium supplements and low-fat dairy products

16. MENOCAL Vit D and Calcium CALCIFEROL 50 000iu

17. Screening / Surveillance Use Gail Model to assess risk www.cancer.gov.brisktool

18. Average Risk ≤1.7% risk in 5 years

19. Risk Management and Surveillance

20. Is It worth Doing a Surveillance Mammogram ? 1.Never 2.Only with strong Family History 3.Over 50 years in most patients 4.Over 40 years in most patients

21. Should I teach my patients BSE? 1.No, does not improve mortality rates 2.Yes, may help

22. Mammogram

24. Screening / Surveillance contd Normal Risk >20 to 40: CBE each 1 to 3 years >/=40: CBE and ? Mammo annually (share decision-making) 50-69: CBE annually and mammo every year or 2 years >/=70Continue while life expectancy ≥ 7 to 10y

25. Screening / Surveillance contd High Risk High risk women should have screening recommendation from a specialist o LCIS o Previous breast cancer o Strong family history breast, ovary, prostate Consider genetic counselling

26. When Is It Worth Doing Gene Testing? 1.Everyone who can afford it 2.5% risk of carrying gene 3.10% risk 4.20% risk 5.50% risk

27. Screening / Surveillance contd High Risk High risk woman should have screening recommendation from a specialist o LCIS o Previous breast cancer o Strong family history breast, ovary, prostate Consider genetic counselling

28. Questions?

29. Diagnosis

30. Early Diagnosis of Breast Cancer Never ignore complaint/ finding of a lump Investigate change in one breast Inflammatory Ca (or recurrence of Ca) may mimic cellulitis – looks like inflammation Cancer may mimic an abscess

31. Early Diagnosis of Breast Cancer cont’d Suspicious signs: Skin dimpling Nipple discharge Change in shape or appearance of breast Axillary glands New nipple inversion

32. Early Diagnosis of Breast Cancer cont’d PREGNANCY DOES NOT PRECLUDE BREAST CANCER

33. Tests Imaging before biopsy Mammo +/- ultrasound (or ultrasound only <35)

34. Aspiration of a Breast Lump

35. Tests cont’d Biopsies Must be experienced operator with training and regular practice Radiologist Pathologist at FNAC clinic GSH (4045292) Surgeon

36. Management of Findings cont’d Err on the side of caution Must find a reason for a breast lump Refer to a surgeon or oncologist if cancer or suspicion of cancer (surgeon)

38. Cancer prevention healthy lifestyle Oncologist / Specialist Domain Primary Care Domain POPULATION RISK MNGT Risk Assessment Primary prevention Counselling Health promotion Risk assessment Screening POPULATION RISK MNGT Risk Assessment Primary prevention Counselling Health promotion Risk assessment Screening INDIVIDUALMNGT Detection & Diagnosis Treatment Survivorship INDIVIDUALMNGT Detection & Diagnosis Treatment Survivorship TERMINAL CARE Primary Care Domain Multi-disciplinary team approach

39. Very Early Breast Cancer Stage 0/ DCIS Stage 1

40. Breast cancer Stages 1-3

41. Where Does Breast Cancer Spread?

42. Breast Cancer

43. Questions?

44. Treatment of Breast Cancer

45. Treatment of Stages 1-3 Surgery Radiotherapy Hormones/Endocrine Rx Biologicals Chemotherapy

46. Oestrogen Receptors Oestrogen Target Cell (e.g. Breast, Uterine lining, Liver, etc.) Non-Target Cell (contains no oestrogen receptor)

47. How Do We Treat HR positive Breast Cancer in Premenopausal Women?

48. Pathway in Premenopausal Women Pituitary Oophorectomy OestrogenOvariesHypothalamus LHRH Agonist FSH LH

49. How Do We Treat HR positive Breast Cancer in Postmenopausal Women?

50. Oestrogen Receptors Oestrogen Target Cell (e.g. Breast, Uterine lining, Liver, etc.) Non-Target Cell (contains no oestrogen receptor)