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Oncology Rehabilitation: Web-based Learning for Physical Therapists
Who Provide Rehabilitation to Patients with Breast Cancer
File #2
Basic Breast Cancer
Basic Breast Cancer
• General oncology information that will assist
physical therapists who desire to work with
patients diagnosed with breast cancer.
2
Who can get Cancer?
• Anyone
– 1,382,400 new diagnosed cases/year
– 269,730 new breast cancer/year
– 1 in 7 women are diagnosed with breast cancer
(www.cancer.org, 2006)
3
Cancer
2nd most common cause of death in
the United States
• Uncontrolled growth and spread of abnormal
•
•
•
cells can result in death.
Over 9.8 million Americans alive today have a
history of cancer. (3 million in 1971)
About 547,000/year people will die of cancer.
About 500,000 (4 of 10) people diagnosed with
cancer will be alive in 5 years.
(www.cancer.org, 2006)
4
Breast Cancer Specific:
• The American Cancer Society estimates in 2006 that …
– there will be 212,920 new cases of invasive breast cancer to be
diagnosed, and 61,980 non-invasive cases.
– approximately 40,970 females are expected to die from breast
cancer.
– about 1,720 cases of breast cancer expected in men, accounting
for <1% of all breast cancer. Approximately 460 men will die of this
diagnosis.
• The National Cancer Institute estimates about 2.3 million
women with a history of breast cancer were alive in 2002.
(American Cancer Society, www.cancer.org, 2006)
5
DORLAND’S ILLUSTRATED MEDICAL
DICTIONARY
• ONCOLOGY (Ong-kol’o-je) The sum of knowledge
•
concerning tumors; the study of tumors.
CANCER (Kan’ser) A cellular tumor the natural course
of which is fatal and usually associated with formation of
secondary tumors.
(Dorland, 1965)
6
What is Cancer?
A large group of diseases
• _________________________________
Uncontrolled growth
• _________________________________
Abnormal cells that lack differentiation
• _________________________________
Uncontrolled spread of abnormal cells can result in death
• _________________________________
Detected and treated promptly, many types can be cured
• _________________________________
(Ward, 1995)
• “This knowledge is of significant importance to
rehabilitation professionals, as they assist patients to
realistically identify and achieve goals within their
abilities and prognosis.”
CDR. Charles L. McGarvey, M.S., P.T.
7
Normal Cell
centriole
mitochondrion
nucleolus
nucleus
•Normal DNA
•Normal growth
•Normal function
8
Cancer Cell
•Abnormal DNA
•Abnormal growth
•Abnormal function
•Characteristics:
•Exhibits uncontrolled growth
•Invades surrounding tissue
•Destroys healthy tissue
•Mutates
•Metastasizes
•Becomes anaplastic
•Has irregular shapes and patterns
9
10
(Slide permitted by the American Cancer Society)
Cell Characteristics
• Benign:
–
–
–
–
–
–
–
–
–
–
Occasionally large
Light to dark staining
Rare mitotic figures
Round oval nucleus
Smooth nuclear edge
Nucleus intact
Nucleoli small if present
Multinuclear cells
Clumps of cells similar
Focus same windows between
cells
• Malignant
–
–
–
–
–
–
–
–
–
–
Many cells may be large
Very basophilic
Many mitotic figures
Irregular (bizarre) nucleus
Edges indistinct and irregular
Nucleus disintegrated edges
Large and prominent
Vary in size and shapes
Clumps vary in size
3-D must focus up and down
to see cells; dark staining
borders, no windows
11
Tissue Evaluation
• Cell staining:
Ability to dye parts of cells to make them
• Cell cultures:
Model for studying active cells in the whole
clearer to inspect.
organism or in vivo.
.
12
•Biopsy:
–Fine-needle aspiration:
Suction from syringe to
gather clumps of cells from a tumor.
–Cutting needle biopsy:
Obtain small core of tissue
–Incisional biopsy:
Surgical removal of small area of tissue.
–Excisional biopsy:
Surgically remove entire tumor for
analysis.
(Altman, 1992)
13
Tumor Nomenclature
• Anatomic site of primary tumor
(Lung, colon, breast).
• Classification of the tissue of origin
(Epithelium, connective tissue)
• Extent of tumor progression
(Degree of invasion or metastasis)
• Degree of cell anaplasia
(Benign or malignant)
14
Tumor
-
Localized swelling or mass
• Benign:
– Tumors can compress, invade and destroy adjacent
normal tissue; do not invade other tissue and
generally not a danger to life.
• Malignant:
– Endanger life. Can choke out normal tissue, and
spread to other parts of the body (Metastases)
through the blood and lymph systems.
(Dollinger et al, 2002)
15
Cell Disorders
• Hyperplasia
• An increase in the number of cells of a
tissue or organ without tumor
formation.
• Dysplasia
• A cell variation in size and shape from
• Metaplasia
• Unusual cell growth. Differentiated
• Anaplasia
• Most serious growth. Absence of
normal. More severe than hyperplasia.
tissue from one kind into another.
normal cellular differentiation in tissue.
Cells divide at an increased rate
compared to normal cells. Found in
most malignancies.
(Otto, 2004)
16
Carcinoma
• Develops in the lining and covering tissues of
•
organs
85 – 90% of all Cancers are generally found in
organs that secrete
– Examples: Lungs secrete mucus, breast secretes milk,
pancreas secretes digestive juices
Carcinoma: in situ: Earliest stage of cancer, with the
tumor confined to a local area.
Sarcomas account for 2% of breast cancer. This
is a solid tumor that originates in connective
tissue, bone, muscle, cartilage or fat.
(Love, 1990)
17
Where breast cancer can develop:
• Milk ducts
• Between ducts
• In fat
• In lymphatic system
• Blood vessels
• Nipple
• Lobes where milk is produced
(Lang, 2005)
18
80% of breast cancers are invasive ductal
carcinoma. Pathologic classifications of less
common types of breast cancer:
• Ductal
– Inflammatory:
Blockage of the lymph drainage
from skin on the breast. Red,
swollen, thick and pitted.
• Lobular
– Paget’s disease:
Affects nipple and areola. Starts in milk
duct as either in situ or invasive cancer.
Good prognosis.
– Medullary:
Invasive,
well defined division of cancer
and non-cancer tissue. Large
Ca cells and immune system
cells around the tumor border.
– Mucinous:
Invasive
cancer cells produce mucus and
grows into a jelly-like tumor.
(Jennings-Dozier et al, 2002) 19
Signs of cancer and risk
factors
7 Warning Signs of Cancer
•
•
•
•
•
•
•
C
A
U
T
I
O
N
change in bowel or bladder habits
a sore that does not heal
unusual bleeding or discharge
thickening or lump in breast or elsewhere
indigestion or difficulty swallowing
obvious change in a wart or mole
nagging cough or hoarseness
(Dollinger, 2002)
21
Additional Warning Signs
Specific to Breast Cancer
Breast discharge or bleeding
Change in shape of breast or nipple
Tender lymph nodes
Skin dimpling
Noted rash or veins of the breast
(Dollinger, 2002)
Risk Factors for Breast Cancer
• Family history (less
• Higher education or
•
•
•
•
•
•
than 7% of breast
cancers are thought
to be hereditary).
Long menstrual
cycles or early
menarche
Late menopause
First pregnancy after
age 30.
•
socioeconomic class
Stress
Obesity
Living in Northern
U.S.
History of colon or
other female cancers.
(Dollinger, 2002)
23
Differential Diagnosis: Before you treat,
make sure the diagnosis is correct.
• Differential diagnosis is the method by which a
•
clinician considers the possible causes of a patient’s
clinical findings before making a final diagnosis.
Patient with diagnosis of breast cancer:
– Breast, lung and prostate carcinomas.
– Be aware of any history of malignancy.
– “Lymphedema is an important differential
diagnosis in limb swelling”
(Tiwari, 2003)
24
25
Breast Cancer Diagnosis
Early detection is optimal
Methods to Diagnose
Breast Cancer
•
•
•
•
•
•
•
History & Physical
Biopsy
•
Fine Needle Aspiration
•
Core Needle Biopsy
•
Surgical Biopsy
•
Mammogram
•
MRI
CT scan
Ultrasound
Bone scan
PET Scan
Tumor tests
(Altman, 1992)
27
Diagnostic tools explained
• Biopsies:
• Fine Needle Aspiration – Removes cells through a thin hypodermic needle
•
•
•
•
connected to syringe and moved in and out of tumor to acquire tissue for
evaluation. Fluid is evaluated by a cytologist. This method used for a
palpated lump, if negative further biopsies needed.
Core Needle Biopsy – A large needle which can yield a tissue sample.
Needle insertion can be guided by ultrasound or a MRI scanner, which is
called image-guided. This tissue study is completed by a pathologist.
Open biopsies are often prescribed to double check or rule out cancer.
Incisional biopsies remove tissue samples through a small incision, enough
tissue for pathologist to confirm his conclusion.
Excisional biopsies remove the entire lump and some healthy tissue
surrounding the lump.
(Braddock, 2002)
28
Diagnosis continues
•
•
•
•
•
•
Mammogram is a technique completed routinely for early detection, This is completed
by compressing the breast and obtaining an oblique and a craniocaudal view. Good
procedure to spot lumps to small to be felt. Patterns of interspersed cords of cancer
cells among the breast tissue make diagnosis and detection difficult.
Magnetic resonance imaging (MRI) Combination of magnetic and radio waves that
are a high sensitivity device which can show the extent of the invasive or noninvasive disease. This procedure is completed by showing blood vessels in tissue.
This tool is valuable for high risk females as well as following neoadjuvant therapy.
CAT scan is computer aided to create a three dimensional images of organs and
structures for further specific diagnosis, if needed.
Ultrasound is a high frequency sound wave beamed through breast tissue and
reflections are detected and turned into images. Cancer cells usually have a distinct
outline compared to normal cells. The results of this examination are operator
dependent.
Bone scan detects increased blood circulation in a bone, which could reveal
metastases.
Pet Scan (Positron emission tomography) similar to X-ray except Pet scans show cell
activity, by detecting the rate cells consume glucose. Cancer cells use up sugar faster
than normal cells.
• Tumor testing can be completed by using estrogen and progesterone
receptors as well as other genetic measurements.
(Dixon, 2006)
29
Mammography
Radiologist read the test results and compare
them to previous mammograms when possible.
30
Non-palpable intraductal
carcinoma
Mammogram
31
(Slide permitted by the American Cancer Society)
Medullary carcinoma: Thought benign but
mammogram and biopsy=suspicion of CA
(Slide permitted by the American Cancer Society)
32
Female Protection Against Cancer
• BREAST - Monthly breast self-exam between
Age 20-40 Health professional breast
check /3yrs
• Age 40 - 1st mammogram
• Age 40-50 - Health professional breast
check/yr; mammogram every 1-2 yrs.
• Over 50 = Health professional and annual
mammogram
SEE HEALTH CARE PROVIDER WITH ANY
CHANGES IN BREAST
(Jennings-Dozier et al, 2002)
33
Male breast cancer
• < 1% of breast cancer
• 1500 new cases and 400 fatalities/year
•
•
•
(Compared to 203,500 new cases in women)
Risk increases with family history of mutated
BRAC2
Prognosis similar to female, testing size, grade
and nodes.
Treatment with mastectomy and other
interventions as prescribed by oncologist.
(Donegan, 2002)
34
PATHOLOGY AND
TUMOR STAGING
35
Specific Staging
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
To
Tis
T1
T2
T3
T4a
T4b
T4c
T4d
No
N1
N2
N3
Mo
M1
no palpable tumor
cancer in situ
< 2 cm
T1a <0.5 cm
T1b >0.5 – 1 cm
T1c >1-2 cm
> 2-5 cm
> 5 cm
involved chest wall
involved skin
T4a and T4b together
inflammatory
no regional node metastasis
palpate morbile ipsilateral axillary nodes involved
fixed ipsilateral axillary nodes
ipsilateral internal mammary lymph node metastasis
no distant metastasis
distant metastasis
(Dixon, 2006)
36
Classification leads to Stage
• Stage 0
– Lobular carcinoma in situ (LCIS) abnormal cells
lining a gland in the breast.
– Ductal carcinoma in situ (DCIS) abnormal cells
lining a duct; has risk of becoming invasive.
Continue
37
Diagnostic Staging
(TNM classification)
Stage 1
Stage 2
Stage 3
Stage 4
Tumor
0-2 cm
2-5 cm
Any size
Any size
Nodes
Negative
Negative or
Positive
Large
Near clavicle
Any nodes
METS
No metastasis
No metastasis
No metastasis
Metastasis
(Abraham, 2005) 38
•C
•P
•R
•A
TNM pre-op clinical diagnosis
TNM post-surgical resection pathology
TNM re-treatment staging--recurrence
TNM autopsy
(Otto, 2004)
39
Note decrease survival with increase stage
40
(Slide permitted by the American Cancer Society)
Time Out Test
• What was the expected total number of breast
•
•
Answers:
274,900 diagnosed; abnormal DNA, growth and function; biopsy; Grade 4;
True; False (Sarcoma is a solid tumor).
•
•
•
cancer expected in 2005?
Name the abnormal activities of cancer cells.
Removing cells and tissue for diagnosis is?
Once metastasis occurs what tumor grade is
recorded?
Doubling refers to cancer growth? T/F
Carcinoma is a solid tumor? T/F
41