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

2. Leading Cancer sites-2010 Male Lip ,oral cavity and pharynx 14.1 %
Bronchus and Lung %
Oesophagus %
Colon rectum %
Female
Breast %
Cervix %
Ovary %
Thyroid %

3. new Cancer patients
new Cancer patients
new Cancer patients
new Cancer patients
new Cancer patients
new Cancer Patients

4. 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

5. 6 5

7. Diagnosis
Triple assesment
Clinical Examination-site,size for staging
Mammogram/US scan in < 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

8. 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

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

10. 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

17. 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

18. 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

20. 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

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

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

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

24. Stage year survival
Stage I T1 NO M %
Stage II T0-1 N1 M0
T2 N0-1 M %
T3 N0 M0
Stage III T0-2 N2 M0
T3 N1-2 M0
T4 any N M %
Any T N3 M0
Stage IV Any T any N M %

25. 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 years
If Clinical Breast examination detects a suspicious lesion under the age of 45 years-US scan breasts and ideally MRI of Breast

26. Thank you