Download Screening for Breast cancer

SCREENING FOR BREAST CANCER
THE OBSTETRICS & GYNECOLOGICAL SOCIETY OF BHOPAL
&
AMPOGS RESEARCH PUBLIC WELFARE SOCIETY
SCREENING TOOLS
• Clinical Breast examination
• Breast self examination
• Mammography
• Ultrasonography/elastography
• FNAC
• Cytology of nipple discharge
AGE STANDARDISED (WORLD) BREAST AND GENITAL TRACT
CANCER INCIDENCE RATES PER 100,000 FEMALES
35
30
25
23.2
21.2
19.3
15.7
17.4
16.6
15
10
5
20.2
19.3
20.1
27.5
24.6
23.3
RATE
20
31.3
28.2
4.8
7.2
7.2
1.3
1.4
1.6
1970
1975
1980
6.5
2.3
7.2
7.6
2.5
2.4
1990
1995
8.3
3.2
0
1985
YEAR
BREAST
CERVIX UTERI
OVARY
CORPUS UTERI
2000
BREAST AND GENITAL TRACT CANCER
BREAST CANCER INCIDENCE
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Most common cancer in women worldwide.
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In India 144,937 women were newly detected with breast cancer in 2012, of which
70,218 women died. Roughly, for every 2 women newly diagnosed with breast
cancer in India, one dies of this disease.
Most common cause of death from cancer among women.
More than three fourths of these women in developing countries are diagnosed in
advanced stage of the disease. If these lesions are detected early, most breast
cancers can be effectively treated with good outcome.
WHO TO BE SCREENED
• Women between the ages of 40-60 years of age
• All women identified with a breast mass that has previously not been clinically evaluated
need to be screened for breast cancer
• Women with high Risk factors can be offered screening from age 30 years such as
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Age over 40
No children or children after 30 years of age
Mother or sister with breast cancer
History of breast biopsies or breast cancer
Initiation of menses before 12 years of age
Overweight
• Screening to be every 2 years
CLINICAL BREAST EXAMINATION - TIPS
• Be sensitive to the woman by giving her opportunities to express any concerns before and during the
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examination.
Respect the woman’s sense of privacy.
If the woman is anxious, assure her that you will do your best to make the examination comfortable.
Throughout the examination, approach the woman slowly and avoid any sudden or unexpected movements.
Do not rush through the examination. Perform each step gently and ask her if she is having any discomfort
during any part of the examination. Be aware of her facial expressions and body movements as indications
that she is uncomfortable.
Always take into consideration any cultural factors when deciding what clothing the woman should remove.
Have a clean sheet or drape to cover the woman’s breast if needed.
These examinations should be performed in a clean, well-lit, private examination or procedure room that has
a source of clean water. A female assistant should be available to accompany the woman when a male
clinician is the examiner.
GETTING READY
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Tell the woman you are going to examine her breasts.
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Wash your hands thoroughly with soap and water and dry them with a clean, dry cloth or allow
them to air dry before beginning the examination.
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If there are open sores or nipple discharge, put new examination or high-level disinfected surgical
gloves on both hands.
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Ask the woman to undress till the waist. With the woman undressed from the waist up, have her sit
on the examining table with her arms at her sides.
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Examine both in sitting and lying down position
This is a good time to ask if she has noted any changes in her breasts and whether she does
monthly breast self-examinations. Tell the woman that you will show her how to do a breast selfexamination before she leaves.
PERFORMING A CBE
• Steps of examination - CBE involves two main parts:
• Inspection to identify physical signs of breast cancer.
• Palpation which involves using the finger pads to physically examine all areas of breast tissue
including lymph nodes (underarm area) to identify lumps
• 4 positions
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Arms by the side of trunk.
Raising arms over the head.
Pressing on the hips.
Leaning forward.
INSPECTION
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In the sitting position first visually inspect the
breast, initially when woman is sitting up right
with arms on her hips, and then with her arms
raised over head.
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Note any change in symmetry of breast
shape, size, skin changes–skin dimpling or
retraction or ulceration the level of both
nipples, retraction of nipple(s), inverted
nipple.
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• Look at the breasts for shape and size.
• Note any difference in shape, size,
nipple or skin puckering or dimpling.
Although some difference in size of the
breasts is normal, irregularities or
difference in size and shape may
indicate masses.
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Swelling, increased warmth or
tenderness in either breast may suggest
infection, especially if the woman is
breastfeeding.
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Look at the nipples and note their size and
shape and the direction in which they point
(e.g., do her breasts hang evenly?). Also check
for rashes or sores and any nipple discharge.
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Have the woman first raise her arms over her
head and then press her hands on her hips to
contract her chest wall (pectoral) muscles. In
each position, inspect the size, shape and
symmetry, nipple or skin puckering or dimpling
of the breast and note any abnormalities.
(These positions will also show skin puckering
or dimpling if either is present.) Then have the
woman lean forward to see if her breasts
hang evenly.
PALPATION
• Have the woman lie down on the examining table.
• Placing a pillow under her shoulder on the side being examined will spread the breast tissue
and may help in examining the breast.
• Place a clean sheet or drape over the breast you are not examining.
• Place the woman’s left arm over her head. Look at the left breast to see if it looks similar to
the right breast and whether there is puckering or dimpling.
• Use “Dial of clock method” for palpation, first use the finger pads of the middle three fingers
to palpate the entire breast, in overlapping circular motions, one area at a time. Repeat both
parts of the examination on both the left and rights breasts.
WOMAN IN LYING DOWN POSITION
Palpation pressure
• Light pressure for
superficial breast
tissue
• Medium pressure for
intermediate layer
• Deep pressure for
tissue close to chest
wall
The finger pads of middle three fingers
should be used to palpate the breast in
circular motion
PALPATION
Pads of three middle fingers, hand
bowed up
JAMA, Vol. 282, No 13, Oct. 1999
Dime size circles
Slide between palpations without
lifting fingers
SPIRAL TECHNIQUE
• Using the pads of your three middle fingers,
palpate the breast using the spiral
technique. Start at the top outermost edge
of the breast. Press the breast tissue firmly
against the ribcage as you complete each
spiral and gradually move your fingers
toward the areola. Continue this until you
have examined every part of the breast.
Note any lumps or tenderness.
CHECK FOR NIPPLE DISCHARGE
• Using the thumb and index finger, gently squeeze
the nipple of the breast. Note any discharge: clear,
cloudy or bloody. Any cloudy or bloody discharge
expressed from the nipple should be noted in the
woman’s record. Although it is normal to have some
cloudy discharge from either or both breasts up to
a year after giving birth or stopping
breastfeeding, rarely it may be due to cancer,
infection or a benign tumor or cyst. Repeat these
steps for the right breast.
AXILLARY TAIL/ LYMPH NODES
• To palpate the tail of the breast, have the
woman sit up and raise her left arm to
shoulder level. If needed, have her rest her
hand on your shoulder. Press along the
outside edge of the pectoral muscle while
gradually moving your fingers up into the
axilla to check for enlarged lymph nodes or
tenderness. It is essential to include the tail
of the breast in the palpation because this is
where most cancer occurs.
DIAL OF A CLOCK METHOD
Palpation will be done in each segment until entire breast is covered.
• Pads of finger (not tips of fingers) of middle three fingers (index, middle and ring) with hand held in slightly bowed position will be
used for palpation.
• In the “dial of a clock” method the whole breast is palpated as if it was a dial of a clock, 12 O’ clock being the highest point at
upper edge of breast just below the midclavicular point and 6 O’ clock being at the inframammary crease. The palpation is begun at
12 O’clock from periphery to the nipple by describing small circles of about 3 cm in diameter. Following circular movement of the
“pad of fingers” 3 times with increasing pressure and without lifting the fingers, the next circle is felt towards the nipple , overlapping
with the previous circle to about half in diameter. Once the areola and nipple area is reached, the next segment /sector is palpated
at 1-O’clock. The procedure of palpation with “pad of 3 fingers” is repeated sequentially at 2 0’ clock, 3 0’, 4 0’, 5 0’, 6 0’, 7 0’, 8
0’, 9 0’, 10 0’ and 11 0’. If a lump is detected, its size should be measured using a Vernier caliper. The palpation of mammary ducts
is done by gently rolling the ducts between the index finger and the thumb. Any thickening, tenderness or discharge is noted while
palpating the mammary ducts. In case of retraction of the nipple an attempt is made to pull the nipple forward to see if the nipple
could be brought forward or not and if any lump is present underneath the areola, whether the nipple and the ducts are tethered to
the lump or not. The skin overlying the lump is gently pinched and moved with the fingers to see if the skin could be moved freely
from /off the lump. If the skin is free from the lump but the movement of lump away from skin causes dimpling of skin, the skin is
considered “tethered”. If no movement of skin is possible, it is considered “fixed”. The fixity of lump to underlying pectoralis major
muscle is ascertained by requesting the lady to push her hand against the hip to contract the muscle and then moving the lump.
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Note any discharge from the nipple(s), colour of the discharge, swelling/ lumps, consistency of the
lumps, swelling in the armpit (axillary area), above the collar bone (supraclavicluar area) and root
of the neck (infraclavicular area).
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Repeat this step for the right side.
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The optimal time for a CBE in a premenopausal woman is 5-10 days after the onset of menses,
avoiding the week before the period is preferable. Postmenopausal women may have CBE
performed at any time. On average, the time required to perform a CBE ranges is 6 to 8 minutes
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Show the woman how to perform breast self-examination.
After completing the examination, have the woman dress herself. Explain any abnormal findings
and what, if anything, needs to be done. If the examination is entirely normal, tell her everything is
normal and healthy and when she should return for a repeat examination (i.e., annually or if she
finds any changes on breast self-examination).
Record your findings
LYMPH NODE EXAMINATION
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Request the patient to sit on a bed or a stool. For axillary nodes palpation,
pectoralis muscle is relaxed by examiner supporting patient’s forearm with his own
forearm, while facing the patient. The medial or central, pectoral and lateral
axillary nodes were palpated from in front while supraclavicular, infraclavicular and
posterior axillary nodes were palpated in sitting position with examiner standing
behind the patient.
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Please record the findings of a skin change, nipple change, nipple discharge, any
lump and lymph node enlargement in axilla or neck on Case record form in a
pictorial manner.
INTERPRETATION & DOCUMENTATION
The results of CBE will be interpreted in the following ways:
• Normal/negative: No abnormality on visual inspection or palpation
• Abnormal: Definite asymmetric finding on either visual inspection
or
palpation. Presence of lump(s) in the breast, any swellings in the armpit,
recent nipple retraction or distortion, skin dimpling or retraction ,ulceration,
any nipple discharge
WARNING SIGNS
The changes that can be seen are:
Unusual increase in the size of one breast
One breast hangs unusually lower
Puckering of the skin
Dimpling or puckering of a nipple or areola
Swelling in upper arm
Change in the appearance of the nipple
Milky or bloody discharge from the nipple
The changes that can be found on feeling the breasts are:
Lump in the breast
Enlargement of lymph nodes in axilla or neck
BREAST SELF EXAMINATION
• It is best to examine your breasts 7–10 days after the first day of the menstrual period. (This
is the time when the breasts are less likely to be swollen and tender).
• You should examine your breasts every month, even after your menstrual period has
stopped forever. If you are no longer menstruating, you should pick the same day each month
(e.g., the first day of the month) to examine your breasts.
• Breast self-examination can be done after bathing or before going to sleep. Examining your
breasts as you bathe will allow your hands to move easily over your wet skin.
BREAST SELF EXAMINATION
• First, look at your breasts.
• Stand in front of a mirror with your arms at
your sides and look for any changes in your
breasts. Note any changes in their size,
shape or skin color or if there is any
puckering or dimpling.
• Look at both breasts again, first with your
arms raised above your head and then with
your hands pressed on your hips to contract
your chest muscles. Bend forward to see if
both breasts hang evenly.
BREAST SELF EXAMINATION
• Size, shape, color
• Even ,no distortion
• Swelling
• Dimpling, puckering, bulging of skin,
• Nipple discharge, position
• Red, sore, rash
Raise hands
Press nipples any
discharge
• Then, feel your breasts.
• You may examine your breasts while standing up or lying
down. If you examine your breasts while lying down, it will
help to place a folded towel or pillow under the shoulder
of the breast you are examining.
• Raise your left arm over your head. Use your right hand to
press firmly on your left breast with the flat surface (fat
pads) of your three middle fingers. Start at the top of the
left breast and move your fingers around the entire breast
in a large spiral or circular motion. Feel for any lumps or
thickening. Continue to move around the breast in a spiral
direction and inward toward the nipple until you reach the
nipple.
Lie flat, arm below, with opposite hand and rotatory
movements, feel for any irregularity in breast.
Collarbone to abdomen, armpit to cleavage.
• Be sure to check the areas between the breast and the
underarm and the breast and the collarbone.
• Raise your right arm over your head and repeat the
examination for the right breast.
In shower, soap
hands,
raise one arm,
feel with opposite
WHAT TO LOOK FOR
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A change in the size or shape of the breast.
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If your breasts are usually lumpy, you should note how many lumps you feel and their locations. Next
month, you should note if there are any changes in the size or shape (smooth or irregular). Using the
same technique every month will help you know if any changes occur.
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Any nipple discharge that looks like blood or pus, especially if you are not breastfeeding, should be
reported to your healthcare provider.
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There may be some discharge from one or both breasts for up to a year after having a baby or
stopping breastfeeding
A puckering or dimpling of the breast skin.
A lump or thickening in or near the breast or underarm area. If the lump is smooth or rubbery and
moves under the skin when you push it with your fingers, do not worry about it. But if it is hard, has an
uneven shape and is painless, especially if the lump is in only one breast and does not move even when
you push it, you should report it to your healthcare provider.
CLINICAL ALGORITHM
CBE
Positive
Negative
Evaluation by surgeons
Reentry into primary screening
Mammography
Ultrasonography
FNAC
Core biopsy
Suspicious of malignancy
Normal
Refer to Medical College/ Regional Cancer
Centre for staging/treatment
NEXT STEP IN THIS CASE
FINE NEEDLE ASPIRATION (FNA)
CORE BIOPSY
SIZE OF BREAST LUMPS
MANAGEMENT OF BREAST
CANCER
RISK FACTORS FOR BREAST CANCER
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Female
Aging
First degree relative had breast cancer /
ovarian cancer.
Menstrual history: early onset, late
menopause
Child birth >30yrs
Long term HRT, 30% increased risk.
Oral Contraceptives, risk slight, risk returns
to normal once the use of OC’s has been
discontinued.
Prior radiation exposure to breast at young
age.
• Breast disease
• Atpyical Hyperplasia
• Intraductal carcinoma in situ
• Intralobular carcinoma in situ
• Obesity, high BMI
• Diet rich in Fats, Alcohol
• Genetic risk factor
• BRCA-1
• BRCA-2
• P53
• Her-2/neu
BREAST CANCER RISK ASSESSMENT
Modified Gail model, 7 factors to calculate risk:
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Age>35 years
First degree relative with breast cancer
Prior breast biopsies – atypical ductal hyperplasia
Age at menarche
Age at first child birth
Ethinicity
Risk of developing breast cancer is indicated by composite score of relative risk for each factor.
FACTORS THAT INFLUENCE SURVIVAL
• Age at diagnosis
• Tumor size
• Stage at diagnosis
• Biologic characteristics of tumor:
• Hormone receptor status (less
significant)
• HER 2
MAMMOGRAPHY
Look for:
• Masses
• Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that
can sometimes indicate an early cancer.
• spiculated appearance
THE STAGES OF BREAST CANCER
Breast Cancer is diagnosed according to stages (stages 0 through IV) under the TNM
classification.
Factors used in staging of Breast Cancer:
• Tumor Size
Size of primary tumor
• Nodal status
Indicates presence or absence of cancer cells in lymph nodes
• Metastasis
Indicates if cancer cells have spread from the affected breast to other areas of the body (i.e.
skin, liver, lungs, bone)
Source: National Cancer Institute
STAGING BREAST CANCER
Stage 0
Ductal carcinoma in situ (DCIS) is very early breast cancer that has not spread
beyond the duct.
Stage I
Tumor is < 2 cm and has not spread outside the breast.
Stage IIA
No tumor is found in the breast, but cancer is found in the axillary lymph nodes,
or tumor is ≤ 2 cm and has spread to the axillary lymph nodes, or tumor is 2-5
cm but has not spread to the axillary lymph nodes.
Stage IIB
Tumor is 2-5 cm and has spread to the axillary lymph nodes or is > 5 cm but still
confined to the breast.
Source: National Cancer Institute
ADVANCED BREAST CANCER
Stage IIIA
The tumor in the breast is smaller than 5 centimeters and the cancer has spread to underarm lymph nodes that are
attached to each other or to other structures, OR the tumor is more than 5 centimeters across and the cancer has spread
to the underarm lymph nodes.
Stage IIIB
Tumor has spread to tissue near the breast (i.e. the skin or chest wall) and may have spread to lymph nodes within the
breast area or under the arm.
Stage IIIC
Tumor has spread to the lymph nodes beneath the collarbone and near the neck, and may have spread to the lymph
nodes within the breast area or under the arm and to the tissues near the breast.
Stage IV
Tumor has spread to other organs of the body (i.e. lungs, liver, or brain).
Source: National Cancer Institute
BREAST CANCER TREATMENT
TNM stage 0
Surveillance LCIS, DCIS
Physical exam, mammography, MRI
Surgery DCIS:
Lumpectomy if DCIS in 1 area,
Mastectomy if DCIS in 2 area or large or
multifocal
Radiotherapy DCIS
Usually accompanies lumpectomy
Hormonal therapy DCIS
In selected ER+ve, for 5yrs lowers cancer
risk.
BREAST CANCER TREATMENT
TNM stage 1 & 2
Breast conservative Surgery
Lumpectomy
Quadrantectomy
Radiotherapy
Axillary dissection
Affected breast chest wall
Adjuvant chemotherapy
Combination chemotherapy 3-6 mths
Adjuvant Hormonal therapy
Premenopausal: tamoxifen in ER+ve,
Postmenopausal: Tamoxifen & aromatase
inhibitor.
BREAST CANCER TREATMENT
TNM stage 3
Surgery
Lumpectomy
Mastectomy
Radiotherapy
Chest wall, regional lymph nodes
Adjuvant chemotherapy
Combination chemotherapy 4-6 mths
Adjuvant Hormonal therapy
If ER+ve or PR+ve,
BREAST CANCER TREATMENT
TNM stage 4
Surgery
Select cases to relieve symptoms
Radiotherapy
Select cases to relieve symptoms and
control local disease.
Chemotherapy
Primary treatment, single agent or
Combination chemotherapy.
Hormonal therapy
If ER+ve or PR+ve,
Monoclonal antibody
HER 2 +ve
LOCAL THERAPY: SURGERY
Local therapy provides adequate control of locoregional disease, includes surgery and radiotherapy.
Surgery:
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Mastectomy:
Modified radical with sentinel LN evaluation
Radical /total mastectomy with sentinel LN evaluation
May include breast reconstruction
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Breast conservation surgery:
Wide local excision
Quadrantectomy
Lumpectomy , includes axillary dissection if disease invasive.
COMPLICATIONS OF SURGERY
• Lymphedema
• 10-305 women who undergo axillary dissection
• 3% if sentinel node biopsy only
• Numbness
• Reduced shoulder mobility
• Psychosocial problems of mastectomy
• Phantom breast sensation
LOCAL THERAPY: RADIOTHERAPY
• Adjuvant radiotherapy in ESBC
• Reduces risk of recurrence
• May improve survival
• Radiotherapy in MBC
• Relieves symptoms such as pain, in pts with bone, brain metastasis while not effecting a
cure.
RT: METHODS OF DELIVERY
• External beam irradiation, to entire breast.
• Partial breast irradiation, including brachytherapy
• Radioactive seeds/pellets placed internally near site of tumor for local effects.
• Can deliver high dose rate radiation, allowing shorter treatment regimes compared to
traditional RT
• 5yr survival rates comparable to whole breast RT.
SYSTEMIC THERAPY FOR BREAST CANCER
• Hormonal therapy
• Chemotherapy
• Targeted therapy
• Clinical trails provide support for optimal implementation for above therapies
in pts with breast cancer.
EVOLUTION OF SYSTEMIC ADJUVANT THERAPY FOR
ESBC
Mastectomy alone
Progressive
improvement in
disease free and
overall survival
Adjuvant CMF
Addition of
Tamoxifen/
Aromatase
inhibitor
Adjuvant CAF, CEF
Adjuvant AC, EC, FEC
Adjuvant AC + T
Dose dense AC+T
TAC
EVOLUTION OF SYSTEMIC ADJUVANT THERAPY FOR
ESBC
PREFERRED CT: MBC
Single agent options:
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Anthracycline – doxorubicin, epirubicin
taxane: - paclitaxel, docetaxel
Capecitabine
Others – vinoretbine, irinotecan
Combination options
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CAF/FAC -docetaxel, capecitabine
AT – paclitaxel, gemcitabine
FEC
CMF
AC, EC – paclitaxel, carboplatin, trastuzumab.
• Single drug/combination controversial topic
• Combinations preferred in MBC
• Newer combinations improve outcome &
manageable safety profile
• Sequential therapy may be appropriate for pts
with indolent disease or nonvisceral MBC>
SUMMARY: ADJUVANT CT IN ESBC
• Adjuvant CT improves survival inESBC
• Improved survival outcomes demonstrated with CMF
• Regimes with anthracycline or a taxane improve outcome
• Dose dense approach has demonstrated benefit in disease free and overall
survival.
TARGETED THERAPY OPTIONS IN BC
• HER2 inhibitor family
• Antibodies
• Trastuzumab
• Small molecules
• Gefitinib
• Erlotinib
• Lapafarnib
• Angiogenesis inhibitor
• Antibodies
• Bevacizumab
CONCLUSIONS
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Although breast cancer incidence has increased, mortality rates due to breast cancer
are reducing.
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Advances in conventional therapy include less radical surgery and reduced radiation
field.
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Cytotoxic CT advances include improved types, doses, scheduling.
Improvements in hormonal therapy.
Newer target therapy
Treatment regimes: individualized.