1. Breast Cancer Breast Cancer DR/FATMA AL-THOUBAITY ASSOCIATE PROFESSOR SURGICAL CONSULTANT

3. Introduction. Introduction. Epidemiology. Epidemiology. Risk factor. Risk factor. Clinical features. Clinical features. Screening. Screening. BSE. BSE.

4. 18.8%. 18.8%. 30.6% less than 40 years. 30.6% less than 40 years. 73.5 % locally advanced disease. 73.5 % locally advanced disease. Breast cancer :a lot to be done’’. JKAU:Med Sci,vol 7,(1999). Breast cancer :a lot to be done’’. JKAU:Med Sci,vol 7,(1999).

5. The most common form of cancer among women. The most common form of cancer among women. The second most common cause of cancer related mortality. The second most common cause of cancer related mortality. 1 of 8 women (12.2%) 1 of 8 women (12.2%) One third of women with breast cancer die from breast cancer. One third of women with breast cancer die from breast cancer.

6. What is breast cancer? Breast cancer is where cancerous (malignant) cells are found in the breast tissue. Breast cancer is where cancerous (malignant) cells are found in the breast tissue. There are several types of breast cancer. There are several types of breast cancer. Ductal cancer (effects the ducts and also is the most common type) Ductal cancer (effects the ducts and also is the most common type) Lobular. Lobular. Inflammatory cancer. Inflammatory cancer.

7. Types of breast cancer In situ In situ Intraductal (DCIS) Intraductal (DCIS) Intralobular (LCIS) Intralobular (LCIS) Invasive Invasive Infiltrating ductal carcinoma Infiltrating ductal carcinoma Tubular carcinoma Tubular carcinoma Medullary carcinoma Medullary carcinoma Mucinous carcinoma Mucinous carcinoma

8. Breast Cancer-Epidemiology #1 noncutaneous cancer in U.S. women #1 noncutaneous cancer in U.S. women >200,000 cases of invasive disease in 2002 >200,000 cases of invasive disease in 2002 #2 cancer death (North American women) #2 cancer death (North American women) (#1=lung cancer) (#1=lung cancer) 40,000 deaths in 2002 40,000 deaths in 2002 1 in 8 lifetime incidence 1 in 8 lifetime incidence 1 in 30 women will die of breast cancer 1 in 30 women will die of breast cancer Incidence increases with age Incidence increases with age

9. Risk Factors for Breast Cancer Female (1% male) Female (1% male) Aging Aging Relative (mother or sister) Relative (mother or sister) Menstrual history Menstrual history early on set early on set late menopause late menopause Child birth Child birth After the age of 30 After the age of 30

10. Exogenous Estrogen Hormonal replacement therapy(HRT) Hormonal replacement therapy(HRT) 30% increased risk with long term use 30% increased risk with long term use Oral Contraceptives(OC) Oral Contraceptives(OC) risk slight risk slight risk returns to normal once the use of OC’s has been discontinued risk returns to normal once the use of OC’s has been discontinued

11. Risk Factors for Breast Cancer Radiation exposure Radiation exposure Breast disease Breast disease Atpyical Hyperplasia Atpyical Hyperplasia Intraductal carcinoma in situ Intraductal carcinoma in situ Intralobular carcinoma in situ Intralobular carcinoma in situ Obesity Obesity Diet Diet Fat Fat Alcoho l Alcoho l

12. Genetics BRCA-1 BRCA-1 BRCA-2 BRCA-2 P53, Rb-1 P53, Rb-1 Her-2/neu, c-erB2, c- myc Her-2/neu, c-erB2, c- myc

13. Incidence of Breast CA Increases with Age

16. Abnormal signs and symptoms Puckering Puckering Dimpling Dimpling Retraction Retraction Nipple discharge Nipple discharge Thickening of skin or lump or “knot” Thickening of skin or lump or “knot” Retracted nipple Retracted nipple

17. Abnormal signs and symptoms Change in breast size Change in breast size Pain or tenderness Pain or tenderness Redness Redness Change in nipple position Change in nipple position Scaling around nipples Scaling around nipples Sore on breast that does not heal Sore on breast that does not heal

18. Methods of Detection Clinical exam by MD or nurse Clinical exam by MD or nurse Mammography Mammography Monthly breast self-exam (BSE) Monthly breast self-exam (BSE)

20. Mammography-Sensitivity Sensitivity is 77-95% overall Sensitivity is 77-95% overall 54-58% in women < 40 54-58% in women < 40 81-94% in women > 65 81-94% in women > 65 Depends on lesion size, conspicuity, tissue density, patient age, hormone status, image quality, and interpretive skill of the radiologist Depends on lesion size, conspicuity, tissue density, patient age, hormone status, image quality, and interpretive skill of the radiologist There is inter- and intra-observer variability in the interpretation by the radiologist There is inter- and intra-observer variability in the interpretation by the radiologist

21. Mammograms Getting a mammogram is an effective way to detect breast cancer in its early stages. Getting a mammogram is an effective way to detect breast cancer in its early stages. It is recommended by the AMERICAN CANCER SOCIETY that all women over 40 get a yearly mammogram. It is recommended by the AMERICAN CANCER SOCIETY that all women over 40 get a yearly mammogram. Its also recommended that women over 20 should get a mammogram every 2-5 years depending on your risk. Its also recommended that women over 20 should get a mammogram every 2-5 years depending on your risk. (picture courtesy of breast cancer.org) (picture courtesy of breast cancer.org).

22. Mammography

24. Why don’t women get MXR’s? Factors that may discourage annual mammography among low-income women with access to free mammograms: a study using multi-ethnic, multiracial focus groups. Bobo JK, Psychol. Rep. Oct. 1999, 85(2). Factors that may discourage annual mammography among low-income women with access to free mammograms: a study using multi-ethnic, multiracial focus groups. Bobo JK, Psychol. Rep. Oct. 1999, 85(2). Fear of radiation, anxiety that may not find CA, worry that CA might actually be detected, embarrassment, discomfort, pain Fear of radiation, anxiety that may not find CA, worry that CA might actually be detected, embarrassment, discomfort, pain Factors assoc. w/ higher rates: Factors assoc. w/ higher rates: higher income, ages 65-74, non-white races higher income, ages 65-74, non-white races Also higher in women who obtain regular check ups or who are vitamin users Also higher in women who obtain regular check ups or who are vitamin users

25. Clinical examination Performed by doctor or trained nurse practitioner Performed by doctor or trained nurse practitioner Annually for women over 40 Annually for women over 40 At least every 3 years for women between 20 and 40 At least every 3 years for women between 20 and 40 More frequent examination for high risk patients More frequent examination for high risk patients

26. Clinical Breast Exam (CBE) Sensitivity is 40-69% Sensitivity is 40-69% Specificity is 86-99% Specificity is 86-99% PPV is 4-50% PPV is 4-50% In one study, only 4% of women with an abnormal CBE had cancer In one study, only 4% of women with an abnormal CBE had cancer

27. Staging of Breast Cancer The American Joint Committee on Cancer (AJCC) has designated staging by TNM The American Joint Committee on Cancer (AJCC) has designated staging by TNM T= tumor size T= tumor size N = lymph node involvement N = lymph node involvement M = metastasis M = metastasis

29. Monthly Self Exams Monthly Self Exams Its important to remember that monthly self exams are also a good tool for early detection. Its important to remember that monthly self exams are also a good tool for early detection. Hereis a web site that has the complete monthly self-exam program @ Hereis a web site that has the complete monthly self-exam program @.cyberus.ca/bse2.htm#bse2 http://www.infobreastcancer.cyberus.ca/bse2.htm#bse2 http://www.infobreastcancer Picture courtesy of Yahoo health Picture courtesy of Yahoo health

30. Breast Self Exam (BSE) Accuracy of BSE is unknown Accuracy of BSE is unknown Estimate of sensitivity: 26-41% Estimate of sensitivity: 26-41% Specificity is unknown Specificity is unknown

31. Breast Self Examination Opportunity for woman to become familiar with her breasts Opportunity for woman to become familiar with her breasts Monthly exam of the breasts and underarm area Monthly exam of the breasts and underarm area May discover any changes early May discover any changes early Begin at age 20, continue monthly Begin at age 20, continue monthly

32. When to do BSE Menstruating women- 5 to 7 days after the beginning of Menstruating women- 5 to 7 days after the beginning of their period their period Menopausal women - Menopausal women - same date each month same date each month Pregnant women – Pregnant women – same date each month same date each month Takes about 20 minutes Takes about 20 minutes Perform BSE at least Perform BSE at least once a month once a month Examine all breast tissue Examine all breast tissue

33. Why don’t more women practice BSE? Fear Fear Embarrassment Embarrassment Youth Youth Lack of knowledge Lack of knowledge Too busy, forgetfulness Too busy, forgetfulness

45. Reference httpbcra.nci.nih.gov/brc/ httpbcra.nci.nih.gov/brc/ httpbcra.nci.nih.gov/brc/ Clinical surgery edited by Michael M.Henry Jeremy N.Thompson.second edition. Clinical surgery edited by Michael M.Henry Jeremy N.Thompson.second edition.