1. Breast Care Leicester Breast Problems - Together we can make a difference Simon Pilgrim MA MBBS MD FRCS Monika Kaushik MBChB MD FRCS Consultant Oncoplastic Breast Surgeons 11 th October 2016 © Simon Pilgrim 2016

2. Who we are Consultant Oncoplastic Breast Surgeons at Nuffield Leicester & Glenfield, UHL General surgery trained but specialising purely in breast surgery Small team of breast specialists Friday evening consultations every week at Nuffield Health Leicester Mammograms & U/S reported live Biopsy results following Friday evening www.breastcareleicester.com Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

3. Aims Overview of current breast cancer management Highlight recent advances & changes Point out potential future developments Breast surgery: Cancer resection & reconstruction Benign Cosmetic breast surgery Q&A Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

4. Staying current: Breast cancer care website (“information and support”): Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

5. Who gets breast cancer? 1:8 women ~13% Commonest female cancer Median age 58 years 53,696 cases per year in UK (344 men 0.6%) 800 per year in Leicestershire & Rutland Almost 8 in 10 (78%) women diagnosed with breast cancer in England and Wales survive their disease for ten years or more (2010-11). Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

6. Route of presentation Symptomatic National Screening (50-70, soon 47-73, self-refer after that) Workplace screening Family history surveillance Post-treatment surveillance Incidentally Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

7. Types of breast cancer? Ductal (75%) Lobular (20% - MRI during work-up) Other invasive subtypes (eg neuroendocrine) “Precancerous” DCIS LCIS (pleomorphic, classical) “DCIS is an early form of breast cancer, where the cancer cells have developed within the milk ducts but remain there ‘in situ’ having not yet developed the ability to spread outside the ducts into the surrounding breast tissue or to other parts of the body.” Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

8. TNM Staging Unhelpful in breast cancer treatment Doesn’t include grade Doesn’t include ER status Doesn’t include lymphovascular invasion Doesn’t include HER-2 status Causes confusion with histological grade Useful research tool Doesn’t help the patient Doesn’t help the family Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

9. Instead of TNM staging: Size of cancer (mm) Location of cancer (quadrant) Locally advanced or not (skin, chest wall, inflammation) Type (Ductal, lobular etc) Grade (1,2,3) ER & HER2 status Nodal involvement (axilla U/S +/- FNA) Distant metastases (CT chest abdomen pelvis) Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

10. Triple assessment of any breast symptom History (pain/mastalgia and previous cysts aren’t especially reassuring) Clinical examination Imaging Mammography, ultrasound, +/-MRI Biopsies Cytology, core biopsy, vacuum biopsy Multidisciplinary review of results Does it all fit? Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

11. How do we treat breast cancer? Surgery Chemotherapy Radiotherapy Endocrine therapy Biologics (soon dual agent biologics) Not at all – patient choice Not with internet-sourced remedies eg alkaline diet Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

12. Adjuvant therapy decision making: Nottingham Prognostic Index (NPI) Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

13. Adjuvant therapy decision making Adjuvant! Online (currently Adjuvant! Offline) Doesn’t include HER-2 Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

14. Adjuvant therapy decision making PREDICT (www.predict.nhs.uk)www.predict.nhs.uk Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

15. Adjuvant therapy decision making Oncotype DX Gene expression profiling of ER+ tumour sample Gives a 10 year “recurrence score” (0-100) based on expression of 21 genes Finds a subset of patients who are considered low risk by the algorithms, but have a high recurrence score based on gene expression Restricted availability on NHS Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016

16. What order do we use these treatments? Conventional: surgery>chemo>radio>endo Neoadjuvant chemo: chemo>surgery>radio>endo Locally advanced/inflammatory To facilitate BCS Node positive at presentation to control systemic spread Indications are increasing, HER-2+ve do especially well Neoadjuvant endo: endo>surgery>chemo>radio>endo Lobulars Primary endocrine: Endo only © Simon Pilgrim 2016

17. Genetics 5% of breast cancers are hereditary InterventionEffect Bilateral risk reducing mastectomy90% RR (or 0.2% per woman-year) Risk reducing bilateral salpingo-oophorectomy0.49 HR Contralateral risk-reducing mastectomy0.03 HR High penetranceModerate penetranceOthers BRCA1 & BRCA2 TP53 PTEN LKB1 PALB2 CHEK2 BRIP1 SNPs 100 000 genome project © Simon Pilgrim 2016

18. Management of the positive sentinel node AMAROS Previously: if axillary U/S normal – sentinel lymph node biopsy If the SLNB is positive – axillary node clearance Now – if SLNB positive – axillary node clearance or axillary radiotherapy Breast Care Leicester www.breastcareleicester.com © Simon Pilgrim 2016