Download Clinical breast exam

Breast Cancer Screening and
Diagnosis
Dr. Ruth Heisey
Family Physician/GP Oncologist
Women’s College Hospital/Princess Margaret Cancer Centre
Clinician Investigator/Associate Professor
University of Toronto
Sandy Fawcett
RN(EC) NP-Adult
Gattuso Rapid Diagnostic Centre
Breast Disease Site
University Health Network- Princess Margaret Cancer Centre
Adjunct Lecturer University of Toronto
May 2, 2014
Canadian Breast Cancer Statistics
• In 2013: 23,800 women will be diagnosed
5,000 will die
• One in nine expected to develop breast cancer
• Mortality rates declining
www.cancer.ca
Objectives:
1. Review current breast screening guidelines
2. Introduce personalized risk assessment
tools
3.
Review strategies for timely breast cancer
diagnosis
Question
Which is the gold standard tool used to screen for
breast cancer?
a) Breast ultrasound
b) Breast MRI
c) Mammogram
d) Clinical breast exam
Breast Cancer Screening Principles
• Breast screening aims to detect cancer
before palpable (pre-clinical phase)
• Early detection leads to better outcome
ONCOLOGY - Cancer biology
Tumor growth and detection
Number of
cancer cells
1012
Diagnostic
threshold
(1cm)
109
time
Undetectable
cancer
Detectable
cancer
Limit of
clinical
detection
Host
death
2011: Breast Cancer Screening Guidelines
CMAJ 2012 Warner et al
The Canadian Task Force screening
recommendations are for average risk women
with no breast symptoms
Screening Mammography
• Canadian Task Force Recommendations:
• “For women aged 50-74, we recommend
routinely screening for breast cancer every two to
three years”
www.ctfphc.org
Screening Mammography
• Canadian Task Force Recommendations:
• “For women aged 40-49, we recommend not
routinely screening for breast cancer with
mammography”
www.ctfphc.org
Screening Mammography
• Canadian Task Force Recommendations (40-
49yo):
• “this recommendation places a relatively low
value on a very small absolute decrease in
mortality… clinicians should discuss the benefits
and harms with their patients and must help each
woman to make a decision consistent with her
values and preferences”
www.ctfphc.org
Effect of Mammographic Screening
(1976-2008)
• Early stage breast cancers-2 fold increase
• Late stage breast cancers-small decrease
• More than 30% of breast cancers detected were
overdiagnosed (would never have resulted in
clinical symptoms if left untreated)
NEJM Bleyer and Welch
Mammographic Screening-Polling Results
NEJM 2013 Feb 368;9, Colbert,Adler
Views on mammographic screening
• Until we can determine which cancers will remain
indolent we must “ treat all (cancers)as potential
killers ”
• Need to prioritize interventions that increase life
expectancy and reduce disease burden
• Agreement that women at greater risk need
vigilant screening
NEJM 2013 Feb 368;9, Colbert,Adler
Clinical Breast Exam
Canadian Task Force Guidelines:
“We recommend not routinely performing
clinical breast examinations alone or in
conjunction with mammography to screen for
breast cancer”
Detection of breast cancer by physical
examination versus mammogram for
different age groups:
50
45
40
35
30
25
20
15
10
5
0
PE only (%)
Mgm only (%)
< 40y
40 -50y
>50y
Clinical Breast Cancer 2005;6(4):330-3
CBE
• Continue as part of periodic health exam or
antenatal visit (opportunistic approach)
What is average risk?
• No family history of breast cancer
• No previous breast biopsies showing atypical
hyperplasia (AH) or lobular carcinoma in situ
(LCIS)
• No history of chest wall radiation
What is higher than average?
Moderate/High:
• History of breast biopsy showing ADH(atypical
ductal hyperplasia), LCIS (lobular carcinoma in
situ)
Previous history of breast cancer
• Family history of breast cancer
What is higher than average?
Very High:
• BRCA carrier or untested first degree relative of
BRCA carrier
• Previous chest wall radiation
• History of LCIS, ADH and family history
Role of Screening MRI
• Definite role for very high risk patients such as
BRCA mutation carriers in conjunction with
mammography and CBE
• MRI more sensitive for detecting breast
cancers than mammography, ultrasound or
CBE alone
• MRI=77-100%
• Mammography=16-40%
JAMA 2004, 292 (11) 1317-25
J Clin Oncol 2006, 23:8469-8476
Magnetic Resonance Imaging ( MRI )
Bilateral breast MRI
American Cancer Society Recommendations
for Screening MRI
Gene mutation (BRCA 1 or 2; Li-Fraumeni syndrome;
Cowden syndrome; Bannayan-Riley-Ruvalcaba
syndrome)
First-degree relative with one of these mutations (if the
woman has not yet been tested)
History of radiation therapy to the chest between ages
10 and 30
Lifetime risk >20-25% based largely on family history
Saslow D, et al. CA Cancer J Clin 2007;57(2):75-89
Warner et al
OBSP High Risk Screening Program- 2011
MRI in addition to mammogram annually
for women ages 30-69:
• known BRCA carrier
• untested first degree relative of BRCA carrier
• chest irradiation before age 30 and at least 8 years
previously
• ≥ 25% lifetime risk of breast cancer (using IBIS or
BODICEA risk calc)
www.cancercare.on.ca
Breast Screening in Clinical Practice
• All women should be asked re: family history of
breast, ovarian cancer or both
• If concerns re: mutation carrier discuss
implications and referral
• Consider mammography screening in all women
starting at age 40 (no woman should be denied!)
Breast Screening in Clinical Practice
The 50-74yo asymptomatic woman:
• Mammogram q 2 years (annual if high risk)
• Consider OBSP
• Discuss breast awareness
• Opportunistic CBE
Breast Screening in Clinical Practice
The 40yo asymptomatic woman:
• Consider mammogram q1-2 years based on risk,
density and patient preference
• Discuss breast awareness
• Opportunistic CBE
Breast Screening in Clinical Practice
The 75yo asymptomatic woman:
• Continue to offer mammography until life
expectancy is less than 10 years
Breast Screening in Clinical Practice
Moderate/High risk:
•Annual mammography and CBE starting at age
40
Breast Screening in Clinical Practice
Very high risk: (e.g. BRCA carrier)
• Annual mammography, MRI starting at age 30
• CBE every 6 months
Personalized Risk Assessment
To determine who should be offered:
• Referral for consideration of genetic testing
• Enhanced screening
• Preventive Therapy
• Surgery
Figure 1:
Management of Women at Risk for Breast Cancer
Lifestyle Modification
Average/
Moderate risk
Mammographic Screening
Referral for Genetic
Counseling
High risk
Enhanced Screening
Preventive
Therapy
Very high risk
Surgery
R B-RST +ve
E IBIS > 20-25%
P GAIL > 3%
S BRCA carrier
Why determine candidates for genetic
counseling?
• 33yo strong family history breast cancer, start
screening digital mammography age 40
At age 42 presents with bloating irregular periodsStage 3c ovarian cancer
• You now take a more thorough family history-
BRCA1 carrier
ref
Why Calculate Risk?
Risk calculators useful in primary care
1. B-RST Tool: determine candidates for referral
for genetic counseling
1. IBIS: determine candidates for enhanced
screening
2. Gail model: determine candidates for
preventive therapy
R: Referral (for genetic testing)
• Two or more first degree relatives same side of
family with breast cancer (maternal or paternal)
• Family members with breast cancer diagnosed
before the age of 50 (maternal or paternal)
• Relative with bilateral breast cancer or breast and
ovarian cancer
• Multiple relatives with ovarian cancer
• Male relative with breast cancer
• Ashkenazic Jewish (Eastern European Jewish)
ancestry
• Relative known to be BRCA mutation carrier
Breast –Referral Screening Tool (B-RST)
•
https://www.breastcancergenescreen.org
B-RST
E: Enhanced screening
• Use IBIS tool to calculate lifetime risk
www.ems-trials.org/riskevaluator
• if lifetime risk ≥ 25% refer to OBSP high risk
program for MRI screening in addition to
mammographic screening
www.cancercare.on.ca/common/pages/UserFile.as
px?fileId=99484
IBIS Risk Calculator:
IBIS: Calculated Risk
P: Preventive Therapy
• Consider for women with strong family history, or
history of atypical hyperplasia or LCIS.
• Use Gail model to assess eligibility for
chemoprevention
http://www.cancer.gov/bcrisktool/
• If 5 year risk ≥3% offer preventive therapy
Gail model:
http://www.cancer.gov/bcrisktool/
Breast Cancer Risk Assessment Tool (GAIL MODEL)
Age
Age at
menarche
5 year risk (>1.66 %)
Age of first
live birth (or
nulliparity)
Number
of breast
biopsies
Family Hx
in first degree
relative
http://www.cancer.gov.bcrisktool/.com
CP1089285-9
Canadian Task Force Recommendations
•
Fair evidence to recommend counseling about the
potential benefits and risks of using tamoxifen to
reduce the likelihood of breast cancer in higher risk
women (B)
• Who qualifies?: A woman with >1.7% 5-year risk
using Gail model
www.ctfphc.org
S: Prophylactic Surgery
• For highest risk women: known BRCA carriers,
or history of LCIS (lobular carcinoma in situ) or
AH (atypical hyperplasia) and a significant family
history
• Always offer reconstruction
Management of Women at Risk for Breast Cancer
Lifestyle Modification
Average/
Moderate risk
Mammographic Screening
Referral for Genetic
Counseling
High risk
Enhanced Screening
Preventive
Therapy
Very high risk
Surgery
R B-RST +ve
E IBIS > 20-25%
P GAIL > 3%
S BRCA carrier
Question
Which is the gold standard tool used to screen for
Breast Cancer:
a) Breast ultrasound
b) Breast MRI
c) Mammogram
d) Clinical breast exam
Clinical Presentation
Most often breast
cancer is first
noticed as a
painless lump in
the breast or
armpit (55%)
Question
What is the most common type of breast cancer?
a) DCIS (Ductal carcinoma in situ)
b) LCIS (Lobular carcinoma in situ)
c) Invasive Ductal Carcinoma
d) Invasive Lobular Carcinoma
Signs and Symptoms
1. Breast lump
•
sometimes detected during a screening
mammogram or clinical breast exam
•
constantly present and does not fluctuate with
menstrual cycle
•
may feel like it is attached to the skin
•
may feel hard and irregular
•
may be tender but not usually painful
Signs and Symptoms
2. Thickening or lump in the axilla
•
•
enlarged lymph node – usually means that the lymphatic system
is fighting an infection in that area
sometimes means that breast cancer has spread to the lymph
nodes
3. Inverted nipple
•
•
may be a normal finding
nipples that become inverted
should be reported
Signs and Symptoms
4. Nipple discharge
• has many different causes and should always
be reported
• may be a sign of cancer if it occurs
spontaneously, bloody, unilateral, uniductal
5. Persistent crusting, ulceration or
eczema-type symptoms on the nipple
• may be a sign of Paget's disease, a rare form
of breast cancer
Signs and Symptoms
6. Changes in breast size and shape
• a change in the outline or
contour of the breast
• a change in the size of the breast
7. Changes in the skin of the breast
• puckering of the skin
• thickening and dimpling of the skin
• redness, swelling and increased warmth in the
breast
Mrs. B
77 yr old postmenopausal woman noticed a non-tender mass in the upper
outer quadrant (UOQ) of the left breast.
PMHx:
Hypertension, obesity. Nulliparous. Menarche 11 Menopause 50.
Mother and maternal aunt - breast cancer- diagnosed age 48 and 51
Clinical breast exam: Breasts are large and in the left breast there was a
firm, mobile, 3.5 x 3.5cm mass palpable at 1 o'clock 6 cm FN. No palpable
left axillary adenopathy. Right breast and axilla were unremarkable.
Next step:
Order diagnostic bilateral mammogram and left breast ultrasound
Mrs. B
Imaging:
Mammography reveals a 3cm mass in the UOQ left breast.
Right breast unremarkable
Left breast ultrasound- 3.3 X 3.2 X 2.0cm hypoechoic area
1 o’clock position 6cm FN.
Left axilla ultrasound: nodes unremarkable
Next step:
Core biopsy
Diagnosis- Tissue Confirmation
Core needle biopsy is the preferred method
• Ultrasound guided
Fine needle aspiration for
axillary lymph nodes
Pathophysiology & Anatomy
Types of Breast Cancer
Invasive (70%)
• Ductal
• Lobular
In-situ (30%)
• Ductal (DCIS)
• Lobular (LCIS)
Other:
Inflammatory
Paget’s, mucinous,
medullary, tubular,
pregnancy induced
Pathophysiology
Mrs. B
Core biopsy left breast 1 o’clock 6cm FN (3.2cm mass)
Pathology:
Invasive ductal carcinoma ER+ PR+ HER2Next steps:
Referral to surgeon
Consider referral to genetics
Healthy living education/ Survivorship program
Referrals to medical and radiation oncology
Question
What is the most common type of breast cancer?
a) DCIS (Ductal carcinoma in situ)
b) LCIS (Lobular carcinoma in situ)
c) Invasive Ductal Carcinoma
d) Invasive Lobular Carcinoma
Questions?