Download Breast Cancer 2/17/2010

Breast Cancer
A Family Medicine Perspective
By Robert R. Zaid, DO
PrimeCare of Novi
Overview
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
Breast Cancer
Epidemiology
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
• Incidence:
– Invasive breast cancer 1
• 1.4 million new cases in 2008
– Incidence rates for 2002 varied internationally
• 3.9 cases per 100,000 in Mozambique
• 101.1 cases per 100,000 in the United States
– Past 25 years
• Breast cancer incidence rates have risen globally
• Highest rates occurring in the westernized countries
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Change in reproductive patterns
Increased screening
Dietary changes
Decreased activity
• Mortality
– Mortality has been decreasing
– Especially in industrialized countries.
1 American
Cancer Society
Breast Cancer
Epidemiology
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
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Staging
Treatment
• Projection (2009)
– United States
– Estimated 192,370 new cases in women
– 1,910 cases in men
• Incidence rates
– 70’s to 90’s had increasing incidence
– 1999-2005
• Decreased by 2.2% per year
• Why?
– Reduced use of hormone replacement therapy
(HRT)
– Women’s Health Initiative in 2002
Swart, R; Downey, L, www.emedicine.com, Breast Cancer
Breast Cancer
Epidemiology
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Epidemiology
Etiology
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Screening
Presentation
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Staging
Treatment
• Lifetime Risk of Breast Cancer
– All Women
• 12.7%
– Non-Hispanic Whites
• 13.3%
– African American Women
• 9.98%
• More likely to be diagnosed with larger,
advanced stage tumors (>5 cm)
Swart, R; Downey, L, www.emedicine.com, Breast Cancer
Breast Cancer
Epidemiology
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Epidemiology
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Screening
Presentation
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Treatment
• Death rates
– Steadily decreased since 1990
– Estimated 40,610 breast cancer deaths
for 2009
– Women < 50 years
• Largest decrease in mortality
• 3.3% per year
• Thought to represent
– Earlier detection
– Improved treatment modalities
Swart, R; Downey, L, www.emedicine.com, Breast Cancer
Breast Cancer
Etiology
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
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Staging
Treatment
• Mechanism– Current understanding of breast tumorigenesis
• Molecular alterations at the cellular level
• Outgrowth and spread of breast epithelial cells
– Immortal features
– Uncontrolled growth
• Genomic profiling
– Demonstrated the presence of discrete breast tumor
subtypes
» Luminal A
» Luminal B
» Basal
» HER2+
– The exact number of disease subtypes and molecular
alterations from which these subtypes derive remains to be
fully elucidated
– Generally align closely with the presence or absence of
hormone receptor and mammary epithelial cell type (luminal
or basal).
Swart, R; Downey, L, www.emedicine.com, Breast Cancer
Breast Cancer
Etiology
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
Breast Cancer
Risk Factors
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
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Staging
Treatment
• Risk factors found by studies
– Many of these factors form the basis for
breast cancer risk assessment tools.
– Common denominator
• Level and duration of exposure to endogenous
estrogen
• Increase lifetime exposure to estrogen
– Premenopausal women
» Early menarche
» Nulliparity
» Late menopause
– Postmenopausal women
» Obesity and hormone replacement therapy
Breast Cancer
Risk Factors
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Epidemiology
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Risk Factors
Screening
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• Family History of breast cancer
– 1st degree relative
• Risk 5 times greater in women with 2
or more first-degree relatives
• A family history of ovarian cancer in a
first-degree relative
– Especially if the disease occurred at an
early age (< 50 years old)
– Associated with a doubling of risk of breast
cancer
Breast Cancer
Risk Factors
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Epidemiology
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• Exogenous hormones
– Oral contraceptives (OCs)
– Hormone replacement therapy
(HRT)
– 1.25 increased risk among current
users of oral contraceptives
• Risk appears to decrease
– As age and time from oral contraceptive
discontinuation increases
– Breast cancer risk returns to that of the
average population after approximately 10
years following cessation of oral
contraceptives
Breast Cancer
Risk Factors
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Epidemiology
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• HRT
– Consistent epidemiologic data support an
increased risk of breast cancer incidence
and mortality (2003) with the use of
postmenopausal HRT
– Directly associated with length of
exposure
• Lobular (relative risk [RR]=2.25, 95%
confidence interval [CI]= 2.00-2.52)
• Mixed ductal–lobular (RR=2.13, 95% CI= 1.682.70)
• Tubular cancers (RR=2.66, 95% CI= 2.163.28).
Breast Cancer
Risk Factors
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Epidemiology
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Combo estrogen plus progestin
– Increased risk as compared to estrogen only
– Not statistical significance (p=0.06)
– Women’s Health Initiative (WHI)
• Indicate that the adverse outcomes associated with long-term use
outweigh the potential disease prevention benefits particularly for
women older than 65 years
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Protective factors
– Late menarche
– Anovulation
– Early menopause (spontaneous or induced)
• Lowering endogenous estrogen levels
• Shortening the duration of estrogenic exposure.
Breast Cancer
Risk Factors
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Epidemiology
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Risk Factors
Screening
Presentation
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Advanced age
Family history
Two or more relatives (mother, sister)
One first-degree relativ
Family history of ovarian cancer in women <50y
Personal history
Personal history
Positive BRCA1/BRCA2 mutation
Breast biopsy with atypical hyperplasia
Breast biopsy with LCIS or DCIS
>4
>5
>2
>2
3-4
>4
4-5
8-10
Reproductive history
Early age at menarche (<12 y)
Late age of menopause
Late age of first term pregnancy (>30 y)/nulliparity
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1.5-2
2
Use of combined estrogen/progesterone
Current or recent use of oral contraceptives
1.5-2
1.25
Lifestyle factors
Adult weight gain
Sedentary lifestyle
Alcohol consumption
1.5-2
1.3-1.5
1.5
Breast Cancer
Risk Assessment Tools
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
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• Multivariate Methods for
estimating breast cancer
– 2 types
• Estimate absolute risk of
developing cancer
• Estimate likelihood that an
individual is a carrier of a gene
mutation
– BRCA1
– BRCA2
Breast Cancer
Risk Assessment Tools
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Epidemiology
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Screening
Presentation
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Treatment
• BRCA screens
– BRCAPRO
• Identifies 50% of mutation negative families
• Fails to screen 10% of mutation carriers
– Myriad I, II
– Manchester
– Ontario Family History
• U.S. Preventive Services Task Force (USPSTF)
– Does not specifically endorse any of these genetic risk
assessment models because of insufficient data to
evaluate their applicability to asymptomatic, cancer-free
women.
• USPSTF does support the use of a greater than 10%
risk probability for recommending further evaluation
with an experienced genetic counselor for decisions
regarding genetic testing.
Breast Cancer
Risk Assessment Tools
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Epidemiology
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Treatment
• Risk Prediction Models
– Gail Model (1989)
• Made from data from Breast Cancer Detection and
Demonstration study
• Probability of developing breast cancer over a defined age
interval
• Intended to improve screening guidelines
– Gail Model 2
• Includes history of first-degree affected family members
• Used extensively in clinical practice
• Most accurate for non-Hispanic White women who receive
annual mammograms
• Tends to overestimate risk in younger women who do not
receive annual mammograms
• Reduced accuracy in populations with demographics (age,
race, screening habits) that differ from the population on
which it was built
• http://www.cancer.gov/bcrisktool/
Breast Cancer
Risk Assessment Tools
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Epidemiology
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• Care
– Address concerns regarding
applicability of the Gail Model to
African American women
– Data from a large case control
study of African American
– CARE Model demonstrated high
concordance between the numbers
of breast cancer predicted and the
number of breast cancers observed
among African American women
when validated in the WHI cohort.
Breast Cancer
Genetic Factors
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Epidemiology
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Treatment
• Heredity
– 5-10% of women have an identifiable familial
predisposition
– 20-30% of women with breast cancer have a
relative with history
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BRCA1 and BRCA2 mutations
– Responsible for 3-8% of all cases of breast cancer
– 15-20% of familial cases
– Gene mutation on Chromosome 17 and 18
• Account for majority of inherited disease
• Believed to be tumor suppressor genes
• Rare mutations are seen in the PTEN, TP53,
MLH1, MLH2, and STK11 genes.
Breast Cancer
Genetic Factors
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Epidemiology
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• Mutation rates may vary by ethnic and
racial groups.
– BRCA1 mutations
• Highest rates occur among Ashkenazi Jewish
women (8.3%)
• Hispanic women (3.5%)
• Non-Hispanic white women (2.2%)
• African American women (1.3%)
• Asian American women (0.5%)
• Women with BRCA1 or BRCA2 gene
– Estimated 50-80% lifetime risk of developing
breast cancer.
Breast Cancer
Breast Cancer Screening
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Epidemiology
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Screening
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• Early detection
– Primary defense available to patients
– Preventing the development of life-threatening
breast cancer
– Breast tumors that are smaller or nonpalpable
• Treatable and have a more favorable prognosis
• Survival benefit of early detection
– Early detection is widely endorsed
• Women younger than 40 years
– Monthly breast self-examination practices
– Clinical breast exams every 3 years are
recommended, beginning at age 20 years.
Breast Cancer
Breast Cancer Screening
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Epidemiology
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Screening
Presentation
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Treatment
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Mammography
– Annual screening mammography beginning at age 40 years
• Widely recommended approach in the United States
– U.S. Preventive Services Task Force (USPSTF) Nov 2009
• Updated breast cancer screening guidelines
• Recommend against routine mammography before age 50 years
• 40 to 49 years of age
– USPSTF suggests that the decision to start regular screening
mammography be individualized and should include the patient's values
regarding specific benefits and harms
– American College of Obstetricians and Gynecologists (ACOG)
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Continues to recommend adherence to current ACOG guidelines
Screening mammography every 1-2 years for women aged 40-49
Screening mammography every year for women age 50 or older
ACOG notes, however, that because of the USPSTF downgrading,
some insurers may no longer cover some of these studies.
Breast Cancer
Breast Self Examination
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Epidemiology
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Treatment
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Breast self-examination
– Inexpensive and
noninvasive procedure
– Evidence supporting
effectiveness
• Controversial and
largely inferred
– Not been found to
reduce mortality
– Improvements in
treatment for early,
localized disease
• Breast selfexamination and
clinical breast
exam, continues
to be
recommended
• Clinical trials
support
combining clinical
breast exam with
mammography
Breast Cancer
Breast Self Examination
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Epidemiology
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Recommendations
– USPSTF
• Inadequate evidence to make a recommendation for teaching or
performing BSE
• 2009 USPSTF guidelines recommend against teaching women
how to perform BSE
• Resulted in additional imaging procedures and biopsies
– ACOG
• Continues to recommend counseling
• BSE has potential to detect palpable breast cancer
Breast Cancer
Mammography
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Epidemiology
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Presentation
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Treatment
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Mammography
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Demonstrated to be an effective tool
Prevention of advanced breast cancer in women at average risk
Best available population-based method to detect breast cancer at an early stage
Often reveals a lesion before it is palpable by clinical breast examination
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20-30% of women still do not undergo screening as indicated
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Physician recommendation
Access to health insurance
Digital Mammograpy
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On average 1-2 years before noted by breast self-examination
Allows the image to be recorded and stored
Computer-aided diagnosis (CAD) systems
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Using an image modified to improve evaluation of specific areas in question.
Breast Cancer
Mammography
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Epidemiology
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• Recommendations:
– USPSTF
• Estimates benefit of mammography in women
– 50-74 years to be a 30% reduction risk of death
– 40-49 years, the risk of death is decreased by 17%
• Non-white women and those of lower
socioeconomic status remain less likely to
obtain mammography services and more
likely to present with life-threatening,
advanced-stage disease
Breast Cancer
Mammography
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Epidemiology
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Screening
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Treatment
• Ultrasound
– Widely available and useful adjunct to
mammography
• MRI
– Combination of T-1, T-2, and 3-D contrastenhanced MRI techniques has been found to be
highly sensitive
• Approximating 99%
– Limitations
• 10-fold higher cost than mammography
• Poor specificity (26%)
• Significantly more false-positive reads
– Significant additional diagnostic costs and
procedures.
Breast Cancer
Mammography
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Epidemiology
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Screening
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Treatment
• Below are the criteria for using breast MRI
screening per the American Cancer Society
(ACS).6
• Annual breast MRI
– Evidence based
• BRCA mutation
• First-degree relative of BRCA carrier, but untested
• Lifetime risk approximately 20-25% or greater as
defined by BRCAPRO or other risk models
– Lifetime risk of breast cancer
• Radiation to chest when aged 10-30 years
• Li-Fraumeni syndrome and first-degree relatives
• Cowden and Bannayan-Riley-Ruvalcaba syndromes
and first-degree relatives
Breast Cancer
Mammography
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Epidemiology
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Screening
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• Insufficient evidence to recommend for or against MRI
screening
– Lifetime risk 15-20%, as defined by BRCAPRO or other
risk models
– Lobular carcinoma in situ or atypical lobular hyperplasia
(ALH)
– Atypical ductal hyperplasia (ADH)
– Heterogeneously or extremely dense breast on
mammography
– Women with a personal history of breast cancer,
including ductal carcinoma in situ
• American Cancer Society does not recommend the
use of breast MRI in women who have less than 15%
lifetime risk
Breast Cancer
Presentation
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Mammogram– Often irst detected as an abnormality on a mammogram
– Mammographic features
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Asymmetry
Microcalcifications
A mass
Architectural distortion
Larger tumors
– May present as a painless mass
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Pain
– 5% of patients with a malignant mass present with breast pain
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Other symptoms
– Immobility
– Skin changes (ie, thickening, swelling, redness)
– Nipple abnormalities (ie, ulceration, retraction, spontaneous
bloody discharge)
Breast Cancer
Workup
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• Core biopsy
– Percutaneous vacuum-assisted
– Image guided breast biopsy
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Recommended diagnostic approach
Performed with
Ultrasound
Stereotactic, or MRI guidance
– Core biopsies spare the need for operative
intervention
• Provides pathological results quicker than surgical
excisions
• Excisional biopsy
– As the initial operative approach
» Shown to increase the rate of positive margins
Breast Cancer
Workup
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Epidemiology
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• Palpation directed core biopsy
– If a breast mass may be palpable but not
correlate with imaging
• Complications of a diagnostic core or
excisional biopsy
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Hematoma
Infection
Scarring
Re-operation
Sampling error resulting in inaccurate
diagnosis.
Breast Cancer
Histological Findings
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Ductal Carcinoma in situ (DCIS)
Lobular Carcinoma in situ (LCIS)
Medullary Carcinoma
Mucinous Carcinoma
Tubular Carcinoma
Papillary Carcinoma
Metaplastic Carcinoma
Mammary Paget’s Disease
Breast Cancer
Histological Findings
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Epidemiology
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• Ductal Carcinoma in situ (DCIS)
– Identified in ducts (non-invasive)
– Identified on mammography
• Suspicious calcifications,
• Distribution
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Linear
Clustered
Segmental
Focal
Mixed
DCIS is divided into comedo (ie, cribriform,
micropapillary, solid) and noncomedo subtypes,
which provides additional prognostic information
regarding likelihood of progression or local recurrence
Breast Cancer
Histological Findings
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• Ductal Carcinoma in situ (DCIS)
– Standard treatment of DCIS is surgical resection
with or without radiation
– Adjuvant radiation and hormonal therapies
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Reserved for
Younger women
Patients undergoing lumpectomy
Comedo subtype
– Mastectomy
• 30% of women with DCIS in the United States
– Conservative Surgery
• 30% with conservative surgery alone
– Conservative surgery with whole breast radiation
• 40% with conservative surgery followed by wholebreast radiation therapy
Breast Cancer
Histological Findings
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Epidemiology
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• Ductal Carcinoma in situ (DCIS)
– Axillary or sentinel lymph node dissection is not
routinely recommended for patients with DCIS
– Metastatic disease
• Disease to the axillary node in 10% of patients
– Whole-breast radiotherapy
• Delivered 5-6 weeks following
– Tamoxifen
• Adjuvant therapy for breast conserving surgery
• Only hormonal therapy currently approved
– Aromatase inhibitor (anastrozole)
• Currently in clinical trials
Breast Cancer
Histological Findings
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Epidemiology
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• Lobular Carcinoma in situ (LCIS)
– Found in the lobules (or glands)
– Non-palpable mass
• Diffuse distribution throughout the breast
• Incidence
– Doubled over last 25 years
– 2.8% per 100,000 women
– Peak incidence is in women aged 40-50 years
– No consistent features on breast imaging
• Often an incidental finding
• 10-20% of women with LCIS develop invasive breast cancer
– Within 15 years from diagnosis.
– LCIS is considered a biomarker of increased breast cancer risk
• Treatment options
– Chemoprevention with a SERM
– Bilateral mastectomy
– Close observation.
Breast Cancer
Histological Findings
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Epidemiology
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• Medullary Carcinoma
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Relatively uncommon (5%)
Invasive
Occurs in younger women
Presentation
• Bulky palpable mass with axillary lymphadenopathy
– Diagnosis
• Sheets of anaplastic tumor cells with scant stroma
• Moderate or marked stromal lymphoid infiltrate
• Histologic circumscription or a pushing border
– Other findings
• DCIS may be observed in the surrounding normal tissues
• ER, PR, and HER2/neu are typically negative, and TP53 is
commonly mutated.
• Roughly 30% of patients have lymph node metastasis.
– Prognosis
• Good
Breast Cancer
Histological Findings
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• Mucinous Carcinoma
– Rare histologic type
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Fewer than 5% of invasive breast cancer
Produces Mucin
Usually presents during the seventh decade
Excellent prognosis (>80% 10-year survival).
Breast Cancer
Histological Findings
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• Tubular Carcinoma
– Uncommon histologic type
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1-2% of all breast cancers
Single layer of epithelial cells
Low incidence of lymph node involvement
Very high overall survival rate
Breast Cancer
Histological Findings
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• Papillary Carcinoma
– 1-2% of all carcinomas
– Usually seen in women older than 60
– Types
• Cystic (non-invasive)
– Good prognosis
• Micropapillary ductal carcinoma (invasive)
– Poor prognosis
– Lymph node metastasis
Breast Cancer
Histological Findings
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Epidemiology
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Risk Factors
Screening
Presentation
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Treatment
• Metaplastic Carcinoma
– 1% of breast cancers
– Combination of adenocarcinoma plus mesenchymal and
epithelial components
– Wide variety of histological patterns
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Spindle-cell carcinoma
Carcinosarcoma
Squamous cell carcinoma of ductal origin
Adenosquamous carcinoma
Carcinoma with pseudosarcomatous metaplasia
Matrix-producing carcinoma
– Metaplastic breast cancer tumors
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Larger
More rapidly growing
Commonly node negative
Typically ER, PR, and HER-2 negative
Average age of onset in the sixth decade
Higher incidence in African Americans.
Breast Cancer
Histological Findings
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Epidemiology
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Treatment
• Metaplastic Carcinoma
– Demonstrated a worse prognosis for
metaplastic breast cancer as compared to
infiltrating ductal carcinoma
– 3-year overall survival rate of 48-71%
– 3-year disease-free survival rate of 15-60%
– Prognosis / predictors of poor overall survival
• Large tumor size
• Advanced stage
• Nodal status does not appear to impact survival
in metaplastic breast cancer
Breast Cancer
Histological Findings
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Epidemiology
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Treatment
• Mammary Paget’s Disease
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1-4% of all breast cancers
Peak incidence is seen in the sixth decade of life (mean age 57 y)
Adenocarcinoma
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Localized within the epidermis of the nipple-areola complex
Paget cells
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Presentation
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Lesions
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Large
Pale epithelial cells
Unilateral developing insidiously
Scaly
Fissured
Oozing
Erythematous nipple-areola complex
Retraction or ulceration of the nipple is often noted
Itching, tingling, burning, or pain.
Mammary Paget disease is associated with an underlying breast
cancer in 75% of cases.
Overall 5-year and 10-year survival rates are 59% and 44%,
respectively.
Breast Cancer
Prognosis
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
– Predictors / prognostic factors of BC
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Axillary lymph node status
Tumor size
Lymphatic/vascular invasion
Patient age
Histologic grade
Histologic subtypes (eg, tubular, colloid [mucinous],
papillary)
Response to neoadjuvant therapy
Estrogen receptor/progesterone receptor status
Her2/neu gene amplification and/or overexpression
Breast cancer predictive factors include the following:
Estrogen receptor/progesterone receptor status
Her2/neu gene amplification and/or overexpression
Lymph node status
Breast Cancer
Staging
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
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T- tumor size
N- Lymph node status
M- Metastasis
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Separated into stages 0- IV
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Survival Rates 5 year
Stages
– 0
• 99-100%
– I
• 95-100%
– II
• 86%
– III
• 57%
– IV
• 20%
Breast Cancer
Staging
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
• National Cancer Center Network
(NCCN) guideline
– Stage I or II
• Recommends a history and physical
examination
• Laboratory studies (CBC with differential, liver
and renal function tests, and calcium levels)
– Stage III
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Chest x-ray or CT scan of the chest
CT scan of the abdomen and pelvis
Bone scan for evaluation of distant metastasis
Tumor markers (CEA and CA15.3 or CA27.29)
may also be obtained in these patients
Breast Cancer
Treatment
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
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Lumpectomy
Mastectomy
Breast Reconstruction
Management of Contralateral breast
Sentinel Node Dissection
Axillary Lymph node dissection
Breast Conserving radiation therapy
Adjuvant Chemotherapy
Adjuvant Hormonal Therapy
• Behavioral therapy--- Very Important
Breast Cancer
Treatment
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Epidemiology
Etiology
Risk Factors
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Presentation
Workup
Staging
Treatment
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Lumpectomy
– Defined as complete surgical resection of a
primary tumor
– Goal of achieving widely negative margins (ideally
a 1 cm margin around the lesion)
– Synonyms for lumpectomy
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Partial mastectomy
Segmental mastectomy
Tylectomy
A quadrantectomy is a type of lumpectomy
Complete removal of the entire affected breast
quadrant
• Performed with palpation guidance or with image
guidance
Breast Cancer
Treatment
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Epidemiology
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Screening
Presentation
Workup
Staging
Treatment
• Mastectomy
– Total mastectomy
• Complete removal of all breast tissue
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Clavicle superiorly
Sternum medially
Inframammary crease inferiorly
Anterior axillary line laterally with en bloc resection of
the fascia of the pectoralis major
– The nipple-areolar complex (NAC) is resected along
with a skin paddle to achieve a flat chest wall closure
when performing a total mastectomy.
– No removal of any axillary nodes
• Modified radical mastectomy
– Total mastectomy with axillary lymph node dissection
Breast Cancer
Treatment
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
• Postmastectomy Radiation
Therapy
– Positive postmastectomy margins
– Primary tumors larger than 5 cm
– Involvement of 4 or more lymph
nodes
• Breast Reconstruction
– SSM
– NSM
Breast Cancer
Treatment
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
• Management of Contralateral breast
• Sentinel Node Dissection
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Technetium 99
Methylene blue dye
First set of nodes that drain from the breast to the axilla
Lymph nodes checked for metastasis
If positive usually recommend axillary dissection
• Axillary Lymph node dissection
Breast Cancer
Treatment
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
• Breast Conserving radiation therapy
– Used to eliminate residual subclinical disease
– Side effects
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Fatigue
Breast pain
Swelling
Skin desquamation
Late toxicity (lasting 6 mo or longer following
treatment)
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Persistent breast edema
Pain
Fibrosis
Skin hyperpigmentation
Breast Cancer
Treatment
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Epidemiology
Etiology
Risk Factors
Screening
Presentation
Workup
Staging
Treatment
• Adjuvant Chemotherapy
• Adjuvant Hormonal Therapy
– Estrogen-receptor positive early
stage breast cancer
• Hormonal therapy plays a main role
• May be used with chemotherapy
• Function to decrease estrogen's ability
to stimulate existing micro-metastases
or dormant cancer cells
• Can reduce the relative risk of distant,
ipsilateral, and contralateral breast
cancer recurrence by up to 50%
Breast Cancer
• Any questions?
• Powerpoint can be found at www.drzaid.com/presentations