Download Early Detection, Diagnosis, Surgical Management, Dr. William (Bill)

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Breast Cancer:
Early Detection, Diagnosis, Surgical Management
2014 WE CAN AFRICAN SUMMIT
September 11-13
Protea Courtyard Hotel
William C. Wood, MD FACS, FRCS Eng (Hon), FRCPS Glasg
Professsor of Surgery, Emory University School of Medicine
Surgical Oncology, Winship Cancer Institute
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Disclosures
I have nothing to disclose relative to this
presentation.
This is a PG-17 presentation.
It contains graphic images.
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Goals of this Talk
• Advocate should be able to identify best efforts to
urge for early detection in their locale.
• Advocate should be able to make the case for accurate
diagnosis and staging.
• Advocate should be able to counsel regarding options
of surgical management.
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Breast Cancer a Global Problem
•
•
• Mortality risk is unevenly distributed:
- High income country
23.9%
- Upper middle income country
38.7%
- Lower middle income country
44 %
- Lower income country
56.3%
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IPRI
INTERNATIONAL
PREVENTION
RESEARCH
INSTITUTE
Stage Distribution around the World
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Centre
is
T0
T1
T2
T3
T4
United
Kingdom
10%
2%
36%
44%
8%
0%
Australia
0%
0%
52%
36%
12%
0%
Hungary
9%
0%
56%
32%
6%
2%
Turkey
0%
4%
26%
48%
14%
8%
Mexico
0%
1%
14%
35%
20%
30%
Oman
0%
0%
10%
45%
14%
31%
Pakistan
0%
0%
4%
68%
24%
4%
Bangladesh
0%
0%
6%
32%
53%
9%
Kenya
0%
0%
0%
0%
76%
24%
20%
48%
26%
6%
5%
35%
56%
25%
51%
18%
Brazil
Uganda
Ethiopia
3%
1%
6%
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Breast Cancer in High Resource
Countries
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Locally advanced disease
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5-Year Survival rates from Breast Cancer in National
Cancer Database (diagnosed 2001 and 2002)
30 April 2017
10
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Importance of Down-Staging
• Stage II moving to Stage I gives 12% better
survival
• Stage IV moving to Stage III gives 30% better
survival, to stage II 50% better
• In lower resource settings, immediate priority
should be to take steps to reduce and eliminate
women first coming to their doctor when their
breast cancer is at such an advanced stage that
cure is no longer an option.
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How to do Early Detection in Africa?
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Population Downstaging of Cancer
• Awareness
• Killing the myths
• Attacking the stigma
• Making diagnosis available nearby
• Making treatment affordable
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First Essential of Cancer Treatment
• The correct pathologic diagnosis
• Obtained by core needle biopsy or fine needle
aspiration cytology
• The pathological diagnosis must fit the clinical
picture
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Can you plan treatment based on a
correct pathologic diagnosis?
The following patients all have the same
diagnosis,
Infiltrating ductal carcinoma of the breast.
Should they all receive the same treatment?
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The Second Essential: STAGING
[Where are we in the story
of this disease?]
Based on TNM Classification and on History
Modified by age and estrogen receptor [ER] status
And by HER-2 expression and proliferation rate
[Histologic Grade, S-Phase, KI-67]
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Stage 0
Tis
Stage I
T1
N0
M0
Stage II
T1
N1
M0
T2
N0,1
M0
T3
N0
M0
Stage III
Any Worse But
M0
Stage IV
Any with
M1
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Needed to Treat Well:
1. Pathologic diagnosis
2. Tumor stage
3. Patient specific goals
4. Available modalities
5. Treat
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Treatment Optimal by Team
• Tumor you see and tumor you can’t see
• Axillary staging by sentinel node biopsy / axillary
dissection if involved nodes are apparent
• Lumpectomy alone: even for small cancers almost
50% recur
• Options: Total mastectomy [optional reconstruction]
or Lumpectomy and Breast Irradiation. Total plus
axillary dissection is called Modified Radical
Mastectomy.
• Then medical Rx [endocrine or chemotherapy]
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Less Morbid Surgical Techniques
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Half-way Through Reconstruction
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Diep Flap With Mastectomy
Awaiting Nipple Reconstruction
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Stage I or II Breast Cancer
• Detected before progression
• With team treatment:
Neo-adjuvant chemotherapy or endocrine Rx
Limited surgery
Skillful irradiation
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Cosmetic Effect of Whole Breast Irradiation
(Standard Fractionation)
Breast Shrinkage at 10 years:
Royal Marsden 2006
START A TRIAL 2013
START B TRIAL
64%
34%
31%
Fair to Poor Cosmesis at 10 years:
-- Canadian 2010
-- Royal Marsden 2006
29%
71%
Eblan MJ et al UNC Lineberger, ONCOLOGY 6/2014
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Goals of this Talk
• Advocate should be able to identify best efforts to
urge for early detection in their locale.
• Advocate should be able to make the case for accurate
diagnosis and staging.
• Advocate should be able to counsel regarding options
of surgical management.
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FINIS
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Example:
Best Outcome for Breast Ca In Unit with Excellent
Radiation Therapy & Med Onc, Clinical N0
• Core-needle Bx for Dx & Receptors
• Neo-adjuvant therapy with clip placed
• Sentinel lymph node biospsy, avoid axillary dissection
• Excision of tumor
• Excellent breast irradiation
• Hormonal Rx if ER +
Surgery is only one element in ideal treatment
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Special Cases: DCIS
[Ductal carcinoma in situ]
• Not cancer, a precancerous condition
• Not an obligate precursor
• Excise to clear margins, add irradiation for DCIS over
2 cm, if possible
• Add tamoxifen if ER positive or unknown
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Special Cases: DCIS
[Ductal carcinoma in situ]
• Not cancer, a precancerous condition
• Not an obligate precursor
• Excise to clear margins, add irradiation for DCIS over
2 cm, if possible
• Add tamoxifen if ER positive or unknown
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Special Cases: LCIS
[Lobular carcinoma in situ]
• Always an incidental finding
• Not a true precursor lesion
• Need not be excised
• A risk factor for later breast cancer, ~ 25% lifetime
• Five years of tamoxifen in premenopausal women,
or aromatase inhibitor in postmenopausal reduces
this increased risk
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Case Examples
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Case A
•60 year old woman, G3P3
•“Aware something was wrong with my
breast for some months, maybe a year…”
•No family history of breast cancer
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Case 1
• 44 yo mother of three, noted new cluster
of calcifications with increased density on
screening mammogram, 3.5 cm diameter,
left central breast.
• U/S shows 4 cm mass with posterior
shadowing. Core biopsy IDC, grade 2/3,
ER+, PR+, Her2 -. Clin T2, N0, M0.
• No family history.
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Case 1
• BCT or mastectomy?
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Case 1
• BCT or mastectomy?
• What staging studies?
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Case 2
• 36 y/o woman, 1.4 cm palpable tumor, medial left
breast. 1 cm soft, low axillary lymph node. Core biopsy
is IDC, grade 1, ER-, PR+, Her2 is 3+ by IHC.
•Past medical history: tobacco 2 ppd x 18 years,
Hodgkins Disease IA presented in neck when 18 years
of age.
•Staging studies?
•BCT? Mastectomy?
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Case 3
65 y/o woman with 2.5 cm, hard, right axillary
lymph node. Mammogram normal, fatty breast.
Core biopsy of node shows IDC, grade 3, ER +,
PR +, Her2 -.
•
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Case 4
• 45 y/o radiologist presents with 2cm focus of
ductal distortion on screening mammogram.
U/S shows vague 2 cm mass.
•Needle core shows invasive lobular Ca, Grade
2/3, ER+, PR-, Her 2 pending.
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Case 5
65 y/o woman with palpable mass excised by
local surgeon. Margins are described as
positive, specimen 2 x 3 x 1.5. Post excision
mammogram showed 1 x 1 cm area of
calcifications adjacent to seroma. ER +, PR +,
Her2 -, 2cm diameter, Grade 2/3 IDC. He
attempted re-excision but DCIS extends to
margins of his re-excision.
•
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Topics:
•Taxanes
•Aromatase inhibitors
•Trastuzumab in breast cancer
•Raloxophene
•Partial breast irradiation - Mammosite
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Case 1
• 44 yo mother of three, noted new cluster
of calcifications with increased density on
screening mammogram, 3.5 cm diameter,
left central breast.
• U/S shows 4 cm mass with posterior
shadowing. Core biopsy IDC, grade 2/3,
ER+, PR+, Her2 -. Clin T2, N0, M0.
• No family history.
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Case 1
• BCT or mastectomy?
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Case 1
• BCT or mastectomy?
• What staging studies?
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Case 2
• 36 y/o woman, 1.4 cm palpable tumor, medial left
breast. 1 cm soft, low axillary lymph node. Core biopsy
is IDC, grade 1, ER-, PR+, Her2 is 3+ by IHC.
•Past medical history: tobacco 2 ppd x 18 years,
Hodgkins Disease IA presented in neck when 18 years
of age.
•Staging studies?
•BCT? Mastectomy?
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Case 3
65 y/o woman with 2.5 cm, hard, right axillary
lymph node. Mammogram normal, fatty breast.
Core biopsy of node shows IDC, grade 3, ER +,
PR +, Her2 -.
•
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Case 4
• 45 y/o radiologist presents with 2cm focus of
ductal distortion on screening mammogram.
U/S shows vague 2 cm mass.
•Needle core shows invasive lobular Ca, Grade
2/3, ER+, PR-, Her 2 pending.
•Also brings MRI showing four additional areas,
6 – 8 mm each, scattered about the same (right)
breast with left breast clear.
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Case 5
65 y/o woman with palpable mass excised by
local surgeon in St. Paul de Vence. Margins are
described as positive, specimen 2 x 3 x 1.5. Post
excision mammogram showed 1 x 1 cm area of
calcifications adjacent to seroma. ER +, PR +,
Her2 -, 2cm diameter, Grade 2/3 IDC. He
attempted re-excision but DCIS extends to
margins of his re-excision.
•
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Implant Only Reconstruction R
Lift on L
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Major Themes
Major themes running throughout the World
Breast Cancer Report 2012 are:
 the global nature of breast cancer;
 the rapid increase in incidence;
 disparities in awareness and response to
symptoms among women;
 disparities in the availability of diagnostic
facilities and treatment options and availability;
 major disparities in breast disease cancer
outcome.
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New Estimates of Burden
• Breast cancer killed 425,000 women in 2010,
of whom 68,000 were aged 15–49 years
living in developing countries.
• Cervical cancer death rates have been
decreasing but the disease still killed 200,000
women in 2010, of whom 46,000 were aged
15–49 years living in developing countries.
Forouzanfar et al (2011)
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Growth of a Public Health
Emergency
Most recent estimates indicate that the global burden
of breast cancer is currently over 1.6 million new
cases annually and that over the past three
decades, the annual burden has been increasing at
an annual rate of 3.1 per cent.
This means that the global burden of breast cancer
will grow by a further 60,000 new cases next year
compared to this year’s total and has grown from
600,000 newly diagnosed cases in 1980 to 1.6
million new cases in 2010.
Forouzanfar et al (2011)
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Breast Cancer Around the World
There are many reports that women in low income
countries, notably Africa, only seek medical
attention when their breast cancer is at an
advanced stage and has frequently spread to other
parts of the body (Stage IV breast cancer).
The prognosis is poor and the only treatment option
is palliation. To help better quantify such stage
differences, the World Breast Cancer Report 2012
collected data on groups of successive breast
cancer patients from Institutes from parts of the
world at contrasting resource settings.
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Global Incidence and Deaths 1
Over the course of the last 30 years, breast cancer has
gone from being considered as a disease of women in
high-income, industrialised countries to being a global
problem.
While the majority of new cases are diagnosed among
women in developed countries, the numbers of deaths
each year from breast cancer are now equally split
between developed and developing countries.
It was estimated that there was a total of 425,200 deaths
caused by breast cancer in 2010. The burden was
equally shared between the developing countries
(213,700) and the developed countries (211,400).
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Global Incidence and Deaths 2
At younger ages (15-49), best estimates are that there
were a total of 94,000 women who died from breast
cancer, with 67,800 (72%) in developing countries
and 26,100 (28%) in developed countries.
At ages above 50 years, there were a total of 331,200
breast cancer deaths worldwide, with 145,900
(40%) in developing countries and 185,300 (60%)
in developed countries.
This is an alarming situation since breast cancer can
have devastating effects on families, particularly in
lower income countries where the majority of breast
cancer deaths in younger women take place.
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Global Priorities
In the current situation, global priorities should be to
reduce:
 the number of women who develop breast cancer;
 the number of women who die from breast cancer;
 the stigma still associated with breast cancer;
 the disparities which currently exist.
Strategies for primary prevention remain in the
research domain while continual progress in the
treatment of breast cancer is advancing slowly but
surely.
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The Growth Pattern of Cancers
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Every Cancer Patient Has Two Stages
1. Clinical stage, based on pre-operative data
2. Pathological stage, based on pathological
material obtained surgically
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Clinical Staging
e.g. for breast cancer:
•
Hx and physical examination
•
Chest film [or CT]
•
Serum alkaline phosphatase
•
[Bone scan only for Stage III]
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Based on the limited
scientific understanding of
oncology available to him,
Halsted realized that hope
of local control of the
tumor required surgery
well beyond the apparent
extent of the cancer.
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Operator
Time
No. of Cases
Local Recurrence
Bergmann
1882-87
114
51-60%
Billroth
1867-76
170
82%
Czeray
1877-86
102
62%
Fischer
1871-78
147
75%
Gussenbauer
1878-86
151
64%
Konig
1875-85
152
58-62%
Kuster
1871-85
228
59.6%
Lucke
1881-90
110
66%
Volkmann
1874-78
131
60%
Halsted
1889-94
50
6%
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Hagensen’s Grave Signs
of Inoperability
• Skin ulceration
• Fixation of tumor to chest wall
• Axillary nodes > 2.5 cm diameter
• Edema of < 1/3rd of breast skin
• Fixed axillary nodes
0 % 5 year disease free, 50% local
failure with any two of these
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Hagensen’s Signs of Bad Outcome
• >50% of skin of breast with edema
• Satellite skin nodules
• Inflammatory breast cancer (heat, redness on > 50%
of breast skin)
• Clinical IM and SCF nodal mets
• Edema of arm
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The Natural History Of Breast Carcinoma
10
Cumulative Survival Rate
9
8
7
Ca
6
5
4
3
2
1
YEARS
10
20
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The Natural History Of Breast Carcinoma
10
Cumulative Survival Rate
9
Control
8
7
Ca
6
5
4
3
2
1
YEARS
10
20
Cumulative possibilities of survival in 622 women treated by radical mastectomy for
carcinoma of one breast, compared to age adjusted survival rates for women in the
general population of New York State.
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Principle
Surgery alone
is only effective
for limited volumes
of malignant disease.
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Lymph Node Involvement as
Staging Data:
No factor or combination of
factors has been shown in
prospective trial
to be as effective a
prognostic descriptor.
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Surrogates for
the likelihood that clinically
unapparent metastasis has
taken place.
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Established Prognostic Factors
• Nodal status
• Tumor size
• Tumor grade
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Why?
You are not
killed by the
cancer you see,
or by the lymph
nodes, but by the
micro-metastatic
cancer that you
cannot see.
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OK?
We now have the diagnosis.
We now have the stage.
Now are we ready to treat?
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Example: Unit without Irradiation
Availability, No Palpable Axillary Nodes
• Core needle Bx (?FNA)
• Total mastectomy with sentinel node biopsy or Level I
axillary dissection
• Adjuvant or neo-adjuvant chemotherapy
• Immediate or delayed breast reconstruction if feasible
With Palpable Axillary Nodes
• Level I & II axillary dissection