Download Breast Cancer - American Medical Student Association

Breast Cancer:
What every medical student should know.
Breast Cancer Awareness
Month
October 2009
For more information:
www.amsa.org
Women agonize... over cancer; we take as a personal threat the lump
in every friend's breast.
Martha Weinman Lear, Heartsounds
Impact:
 With 1 million new cases in the world each year, breast
cancer is the most common malignancy in women and
comprises 18% of all women’s cancers.
 Breast cancer incidence in women in the United States is
1 in 8 (about 13%). Women have a 3% chance of breast
cancer causing their death.
 For women in the U.S., breast cancer death rates are
higher than those for any other cancer besides lung
cancer.
 The American Cancer Society estimates that each year,
about 2000 new cases of invasive breast cancer are
diagnosed in men.
 It is estimated that about $8.1 billion is spent each year
on breast cancer treatment in the U.S.
Epidemiology:
 Over 75% of women who are diagnosed with breast cancer are age 50 or older.
 The five-year relative survival rate is now 98 percent for women with breast cancer caught
before it spreads beyond the breast (compared to 72 percent in 1982).
 Breast cancer incidence is greater in
women of higher socioeconomic background.
The relationship of breast cancer risk
with
socio-economic factors is most likely related to
life style differences like number of pregnancies
and age at first
childbirth.
 Death rates have been decreasing since 1990.
decreases are thought to be the result
advances, earlier detection through
awareness.
These
of treatment
screening, and increased
Incidence and Mortality of Female Breast Cancer
Based on Race and Ethnicity in the U.S.
Rate
Per
100,000
About 90% of breast cancers are due to genetic
abnormalities that happen as a result of the aging process
and life in general, not to inherited mutations.
Probabilities of Developing Invasive Breast Cancer Based on Age
Current
Age
Probability of breast cancer
in next 10 years
20
0.05% or 1 in 1,837
30
0.43% or 1 in 234
40
1.43% or 1 in 70
50
2.51% or 1 in 40
60
3.51% or 1 in 28
70
3.88% or 1 in 26
Lifetime risk: 12.28%; 1 in 8 women
Hereditary Breast Cancer:
 While about 20-30% of women diagnosed with breast cancer have a family
history of breast cancer, only about 5-10% of breast cancer cases are caused by
inherited gene mutations. BRCA1 and BRCA2 mutations are the most
common.
Lifetime breast
cancer risk
Median age of breast
cancer (years)
General population
12%
61
BRCA1
65%
43
BRCA2
45%
41
Breast Cancer Kills Men,Too.
Risk factors for male
breast cancer
Testicular abnormalities: cryptorchidia, congential
inguinal hernia, orchiectomy, orchitis, testicular trauma
Hormonal alterations:
Infertility, Klinefelter’s syndrome, obesity, cirrhosis (and
heavy alcohol intake)
Family history of breast cancer, mutations in
BRCA1/2, CHEK2, PTEN
Benign breast lesions:
Nipple discharge, breast cysts, breast trauma
Exposure to radiation or high temperatures
Old age
Jewish descent
 Less than 1% of all new breast cancer cases
occur in men.
 Men with a BRCA1 mutation have a 1% risk of
developing breast cancer by age 70; BRCA2
mutations confer a 6% risk.
 Breast cancer prognosis, even in stage I cases, is
worse in men than in women.
 Treatment for male breast cancer has usually
been a mastectomy, which may be followed by
radiation, hormone therapy (such as with
tamoxifen), or chemotherapy.
Types of Breast Cancer
DCIS: Ductal Carcinoma In Situ
LCIS: Lobular Carcinoma In Situ
IDC: Invasive Ductal Carcinoma
ILC: Invasive Lobular Carcinoma
Inflammatory Breast Cancer
Male Breast Cancer
Recurrent and Metastatic Cancer
Invasive ductal carcinoma (IDC) is the most
common type of breast cancer, comprising
about 80% of all breast cancers.
Ductal carcinoma in situ
(DCIS) is the most common
type of non-invasive breast
cancer.
Signs to watch out for:
 a lump felt in the breast
 an inverted nipple
 nipple discharge (clear or bloody)
 nipple pain
 sores on the nipple and areola
 enlarged lymph nodes under the arm
Signs and Symptoms
Rapid change in the appearance of one
breast (days or weeks), with visible
enlargement of one breast,
discoloration with red, purple, pink or
bruised appearance and warmth of the
affected breast suggests Inflammatory
Breast Cancer.
In inflammatory breast cancer, cancer cells invade local lymphatic ducts, impairing drainage
and causing edematous swelling of the breast.
Peau d’orange: The skin of the breast is tethered by the suspensory ligament of Cooper,
which, with the accumulation of fluid, can cause the breast to take on a dimpled appearance
similar to an orange.
Inflammatory Breast Cancer
 Inflammatory breast cancer (IBC) accounts for between 1 percent and 6 percent of all
breast cancer cases in the United States.
 The 5-year survival rate for patients with IBC is between 25-50 percent, significantly
lower than the survival rate for patients with non-IBC breast cancer.
 IBC has a high risk of recurrence and is the most aggressive kind of breast cancer. IBC is
more likely to have metastasized at the time of diagnosis than other breast cancer types.
 IBC affects women at an average age of 59 — about three to seven years younger than
the average age at which other types of breast cancer are diagnosed.
 Men can develop the disease, but at an older age. Black women are slightly more likely
than are white women to have IBC.
Risk Factors
 The most significant risk factors for
breast cancer include gender (being
female) and age (growing older).
 Factors with minimal or no risk
include fertility treatment
abortion, deodorant and folic acid.
 Short-term use of hormones for
treatment of menopausal symptoms
appears to confer little or no breast
cancer risk.
Factors that Increase the Relative Risk (RR)
for Breast Cancer in Women
RR>4.0
• Female
• Age (65+)
• Inherited genetic mutations associated with breast cancer such as BRCA1/BRCA2
• Two or more first-degree relatives with breast cancer diagnosed at an early age
• Personal history of breast cancer
• High density breast tissue
• Biopsy-confirmed atypical hyperplasia
2.1<RR<4.0
• One first-degree relative with breast cancer
• High-dose radiation to chest
• High bone density (post-menopausal)
1.1<RR<2.0
Factors affecting circulating hormones:
• Late age at first full-term pregnancy (>30 yrs)
• Early menarche(<12 yrs)
• Late menopause
• No full-term pregnancies
• No breastfeeding
• Recent oral contraceptive use
• Recent and long-term hormone replacement therapy
• Obesity
Other factors:
• Personal history of endometrium, ovary or colon cancer
• Alcohol consumption
• Height (tall)
• High socioeconomic status
• Jewish heritage
Breast Cancer Screening and Prevention

Surveillance
Mammography
Sonogram
MRI
Clinical and self breast exam

Risk Avoidance
Diet and Exercise

Chemoprevention
Tamoxifen
Raloxifene

Prophylactic Surgery
Bilateral Prophylactic Mastectomy
Oophorectomy
Mammograms:
for low-income women and the uninsured.

Mammograms are usually covered by health insurance for women in the
recommended age bracket. While some insurance plans have no out-of-pocket
expenses required, others charge a $10-$35 co-pay.

Uninsured patients pay the full-price cost of a mammogram, which ranges from
$80 to $120.

Some state and local health programs and employers provide mammograms free or
at low cost. Health departments, hospitals, women’s centers, or other community
groups may also have information on how to access low-cost or free mammograms.

The Centers for Disease Control and Prevention (CDC) coordinates the National
Breast and Cervical Cancer Early Detection Program to provide screening services,
including clinical breast exams and mammograms, to low-income, uninsured
women throughout the United States. Visit the CDC website to find contact
information for local programs

Information about low-cost or free mammography screening programs is also
available through NCI’s Cancer Information Service (CIS) at 1–800–4–CANCER
(1–800–422–6237).
Conventional Treatments
 Surgery
 Chemotherapy
 Hormonal therapy
 Radiation
 Just over the horizon: breast cancer
vaccine trials are under way with
vaccines like NeuVax, which stimulates
anti-Her2 immune response, and
Stimuvax, moving into phase III trials.
Triple Negative Breast Cancer:
 Triple negative breast cancer (TNBC) is clinically characterized by the lack of expression of
estrogen, progesterone and HER2 hormone receptors.
 Comprises about 10-20% of breast cancers: more than one out of every 10.
 Does not respond to current hormonal therapy (such as tamoxifen or aromatase inhibitors) or
therapies that target HER2 receptors, such as Herceptin (trastuzumab). Women diagonosed
with TNBC generally face a poorer prognosis.
 Treatments that target other processes may be helpful in treating triple negative breast cancer
when combined with chemotherapy:
 Avastin: interferes with VEGF (vascular endothelial growth factor), inhibiting the growth
of new blood vessels at the tumor site.
 Erbitux: interferes with EGFR (epidermal growth factor receptor), which is often
overexpressed in triple negative cancer.
 PARP inhibitors: inhibit poly (ADP-ribose) polymerase, an enzyme used by cancer cells
to repair DNA damage. One PARP inhibitor, dubbed BSI-201, has been shown to improve
survival in triple negative breast cancer patients by 60% when added to standard
chemotherapy drugs.
Physical changes to the breasts and
side effects such as hair loss, fatigue
and lymphedema
Changes in sexuality and
desire, premature
menopause, infertility
The Breast Cancer
Experience
Mental and emotional changes
such as “chemobrain,” depression
and fear of recurrence
Positive lifestyle changes such
as increased exercise, healthier
eating, stress reduction
Financial hardships,
occupational changes
Changes in relationships with
family and friends
Complementary medicine can improve
quality of life for breast cancer patients:
 Acupuncture
 Spirituality & Prayer
 Meditation
 Reiki
 Aromatherapy
 Support Groups
 Guided Imagery
 Tai Chi
 Hypnosis
 Shiatsu
 Journaling
 Yoga
 Chiropractic Therapy
 Music Therapy
 Massage
 Progressive Muscle
Relaxation
 In the year 2008, there were about 2.5 million
women in the U.S. who considered themselves
breast cancer survivors.
Advocacy