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BREAST CANCER
Oncology
John Dewar
Breast Cancer
Commonest cancer in women
2nd commonest cause of death from
cancer in women
Survival improving – 5 yr. survival
improved from 56% 1970 to 79% in
1999 (year of diagnosis)
Increasing incidence – ageing
population
Presentation
Screening – age 50-64(70), small,
impalpable
Symptomatic – lump in breast
8% with distant metastases
8% locally advanced/inoperable
84% operable
TREATMENT
Surgery
Radiotherapy
Systemic therapy
hormonal therapy
cytotoxic chemotherapy
immunotherapy
RADIOTHERAPY
Postoperatively to
breast/chest wall
nodal areas: axilla, supraclavicular
fossa, internal mammary nodes
Primary radical for locally advanced
Palliatively to painful bony mets, skin
deposits, brain mets etc.
POSTOPERATIVE
RADIOTHERAPY
Reduces the risk of local recurrence by
about two thirds:
60% to 20%
30% to 10%
3% to 1%
POSTOPERATIVE
RADIOTHERAPY
All patients being treated conservatively
(wide local excision/lumpectomy)
Mastectomy patients selectively – large
tumour, extensive nodal involvement,
involved margins etc.
Postoperative Radiotherapy –
acute side effects
Skin erythema to moist desquamation
Tiredness
Dysphagia if irradiating supraclavicular
fossa
No alopecia
Postoperative Radiotherapy –
late effects
Local fibrosis and telangectasia
Lung fibrosis (rarely symptomatic)
Cardiac damage (ischaemic heart
disease) – rarer now treatment better
planned
Postoperative Radiotherapy –
late effects
Survival
Overall 5% improvement in breast
cancer survival (at 15 yrs.) for 20%
improvement in local control (4%
improvement in overall survival)
Localised local recurrence can act as
nidus for distant metastases
SYSTEMIC THERAPY –
adjuvant
Most operable, why not curable?
Occult distant metastases at
presentation
Systemic therapy after surgery reduces
the risk of recurrence and death –
adjuvant therapy
SYSTEMIC THERAPY –
adjuvant
Hormone therapy: ovarian ablation,
tamoxifen, aromatase inhibitors (ER/Pg +ve
patients only)
Cytotoxic chemotherapy: CMF,
doxirubicin/epirubicin, taxanes
Trastuzumab [Herceptin]
All decrease odds of death by about 17%,
absolute benefit of about 6% at 10 years.
SYSTEMIC THERAPY –
adjuvant: side effects
Hormone therapy:
Infertility
Menopausal
symptoms
Weight gain
Endometrial cancer
Deep venous
thrombosis
Chemotherapy
Nausea & vomiting
Infertility
Alopecia
Neutropenia (sepsis)
Mouth ulcers
Lassitude
METASTATIC DISEASE
Incurable but treatable
Optimise quality of life and survival
Median survival with mets: 2 years
(20% at 5 yrs.)
Varies from acute aggressive disease to
chronic disease (like diabetes, renal
failure etc.)
METASTATIC DISEASE
Assess extent of disease
Stage: local recurrence, lung, liver, bone
Hormone receptor status
HER2 receptor status
METASTATIC DISEASE
Local problems
Palliative radiotherapy: bony mets, brain
mets etc.
Drainage of pleural or peritoneal
effusions
Pining of pathological fractures
METASTATIC DISEASE
Systemic therapy
Hormone therapy if ER/Pg +ve
Chemotherapy
Bisphosphonates for bony mets
Trastuzumab if HER2 +ve
METASTATIC DISEASE
Systemic therapy
ER +ve: Hormonal agents: ovarian
ablation, aromatase inhibitors,
tamoxifen, progestagens in sequence
unless liver mets or lymphangitis
carcinomatosa when usually
chemotherapy
METASTATIC DISEASE
Chemotherapy: CMF, anthracyclines,
taxanes, capcitabine etc. etc.
Use in sequence so long as respond
and patient fit
BREAST CANCER
Need multidisciplinary management:
nurses, surgeons, radiologists,
pathologists, oncologists, GP. etc. etc.
Different patients have different needs
Most will need considerable support
Major impact on the patients but also
their families