1. Breast Cancer Screening, Family History Assessment and New Innovations Miss Karina Cox Consultant Breast and Oncoplastic Surgeon

2. Introduction NHSBSP/ ABS Audit 2012/2013 Patients outside NHSBSP age Family History services including testing for breast cancer susceptibility genes Tomosynthesis Intra-operative Radiotherapy Microbubble Project Update

3. NHSBSP History The NHSBSP began in 1988. By 2005, the programme was screening 1.3 million women aged 50–70 years annually. 10 000 breast cancers diagnosed. Age extension

4. NHSBSP/ABS Audit 2012/2013 2 million women screened 20,000 cancers detected 79% invasive, 20% non- invasive and 1% micro- invasive Cancer detection rates 8.4 per 1000 women screened (approximately half are <15mm) Proportion of cancers diagnosed in women 47-49 and 71-73 has increased from 6.2% in 2010/11 to 9.9% in 2012/13.

5. NHSB SP/ ABS Audit – 5 year Survival (women screened in 2007) All invasive cancers 98.5% (was 93.7% in 1990). Tumours <15mm more than 100% Tumours >50mm 89.8% Grade 1 more than 100% Grade 3 – 92.6% Node negative – 100% Node positive – 93%

6. Patients outside of screening age Breast Cancer becomes more common as women age Breast Cancer in the elderly can be an aggressive disease Women above the age of 73 can request screening mammograms from the NHSBSP Healthy, fit women should continue to have screening mammograms

7. Family History and Genetic Testing A significant family history is the strongest individual risk factor for the development of breast cancer. The vast majority of breast cancer in the UK is sporadic and inheritance of cancer- predisposing genes only contributes to 4- 5% of all breast cancer cases.

8. Risk Assessment Several risk assessment tools Developed by Clinical Genetics units Aim to identify women at risk because of their family history

9. BRCA-1/2 – Gene mutations The BRCA 1 and 2 genes are large and sited on the long arms of chromosomes 17 and 13 respectively. Autosomal dominant Some ethnic groups, such as Ashkenazi Jews/ Icelanders have persistent mutations.

10. BRCA-1/2- Gene Carriers Once identified can opt for screening (MRI) or risk-reducing surgery Variant of unknown significance?

11. Identifying BRCA-1/2 gene carriers when diagnosed with breast cancer Future risk of a second ipsilateral breast cancer and 20- 30% risk of contralateral breast cancer. ‘Fast-track’ genetic testing BCS and radiotherapy result in poorer cosmetic outcomes with subsequent mastectomy and radiotherapy. Autologous free flaps can often be used to fashion 2 breasts

12. Tomosynthesis It is a newly developed form of three dimensional imaging with the potential to improve the accuracy of mammography by reducing the tissue overlap and therefore to differentiate malignant features from non- malignant ones

13. Tomosynthesis

14. Intra-operative Radiotherapy (Results of TARGIT Trial) RCT - either a single dose of IORT or EBRT. All the patients were over the age of 45, ER +, IDC and <3.5cm. The rate of local recurrence in the conserved breast at 5 years was 3·3% (95% CI 2·1–5·1) for TARGIT versus 1·3% (0·7–2·5) for EBRT (p=0·042).

15. Intra-operative Radiotherapy (Results of TARGIT Trial 2014) If IORT given at same time as surgery then 2.1% (95% CI 1.1 – 4.2) for IORT and 1.1% (95% CI 0.5 -2.5) for EBRT with an absolute difference of 1%. Not statistically significant. There were no differences in breast cancer related death between the 2 groups but the EBRT group had a significantly higher risk of non-breast cancer death as well as higher radiation associated toxicity.

16. Microbubbles Update

17. Breast Cancer Kent Formerly the Mid Kent Breast Cancer Research Appeal. www.breastcancerkent.org.uk

18. Questions?