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Updates on Breast Cancer
Dr. Noha Al-Saleh,FRCSC
Surgical Oncologist
Kuwait cancer control center and
AlSeef Hospital
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Statistics of breast cancer in Kuwait
What is breast cancer?
Who is @ risk for breast cancer?
Signs of breast cancer
Early detection plan
Treatment of breast ca
Summary of the facts
Statistics of breast cancer
• Breast cancer is the most common cancer
among women.
• It is the 2nd leading cause of cancer deaths
in women today (after lung cancer).
• Deaths declined likely from earlier
detection and advances in treatment.
• Life time risk for breast ca is 1 in 8 women.
• About 1 in 35 women die from breast
cancer in U.S
Statistics in Kuwait
Statistics in kuwait
• Amongst Kuwaiti women, rate of breast
cancer was noted to increase dramatically
for the past few years.
• Between year 1980-1989 the recorded
number of cases was 314.
• This increased to 1555 cases between
years 2000-2009( 5 fold increase).
Statistics in Kuwait
• The age- standardized incidence rate of
new breast cancer cases was 29.7 per
100,000 females in 1980-1989.
• It increased by more than one and half fold
in the following years and reached 49.4
cases per 100,000 females in 2000-2009.
Recent statistics in Kuwait
2012 cancer registry
• Estimated age-standardized incidence rate
for Kuwait was 46.7 per 100,000
population.
• It is higher than that estimated for the
world 43.3 per 100,000 population.
What is breast cancer?
Breast anatomy:The breast is
composed of ducts and lobules
A ducts
B lobules
C dilated section of
duct to hold milk
D nipple
E fat
F pectoralis major
muscle
G chest wall/rib
cage
• Cancer occurs when breast cells that
line up the ducts become malignant
(cancerous)
• Malignant cells are made up of
abnormal cells that grow out of control
and invade normal breast tissue.
• Can spread outside the breasts to other
parts of the body
Risk factors for breast cancer
Factors you CAN change:
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Don’t drink alcohol
Being overweight or gaining wt
Taking birth control pills >5yrs
Having had your first child after age 30
(breastfeeding is protective)
• Having no children
• Using some form of hormone replacement
therapy (HRT) for menopausal symptoms
• Being exposed to large amounts of
radiation.
Factors you CAN NOT
change:
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Being a female
Getting older
Having already had breast cancer
Having certain mutated breast cancer
genes (BRCA1&2)- family history (mother,
sister)
• Having your first period before age 12
• Having started menopause after age 55
• Having a breast biopsy that showed
atypical hyperplasia or carcinoma in situ.
Classification of breast cancer
Divided into two major groups:
(1) In situ cancers  refer to breast tumors
where the tumor cells remain confined
within the ducts of the breast and show no
evidence of invasion into surrounding
breast tissue
(2) Invasive or infiltrating cancers  invade
into breast tissue
Incidence of breast cancer
Warning signs of breast
cancer
• A lump or thickening in the breast or
underarm area.
• Change in size or shape of the breast.
• Nipple discharge or tenderness or nipple
pulled back (inversion) into the breast.
Locally advanced breast ca
What can you do?
(1) Breast self-examination
When to do BSE?
• Check your breasts on a regular basis, for
example, once a month
• Check 5 to 10 days after your period starts
so your breasts will be less tender.
• Irregular Periods? Pregnant? No longer
have a period? Pick the same day of the
month.
Clinical breast examination
• Clinical breast examination (CBE) seeks to
detect breast abnormalities or evaluate
patient reports of symptoms to find
palpable breast cancers at an earlier stage
of progression.
• earlier detection of palpable tumors
identified by CBE can lead to earlier
therapy.
• CBE is regarded as an adjunct to
mammography
• Neither CBE nor mammography is a
substitute for the other as an independent
examination for detecting breast
abnormalities. When a suspicious mass is
found on CBE, it must be evaluated and
explained even if mammography
examination does not show an
abnormality.
Breast screening guidelines
• If you are under age 20- be familiar with
your breasts
• If between 20-39 have regular BSE every
month and every1-3yearly physical
examination
• If between 40-49 you should have annual
physical examination, mammogram every
1-2 yrs and monthly BSE
• Above 50 yrs of age, you should have
annual physical examination, annual
mammogram and monthly BSE
Diagnosis of breast cancer
Mammogram
• Mammogram is the best screening tool
widely available to detect breast cancer
early
• It is a low dose x-ray picture of the breast,
safe
• Has the ability to detect breast cancers
before they can be felt
• Mammography has a sensitivity of about
85% to 90% in women older than 50 years
of age
• for women between the ages of 40 and
50, sensitivity is about 75% and is lower in
women younger than age 40.
• mammography will miss 1 in every 4
breast cancers in women between the
ages of 40 and 50.
• Clinical breast examination is required to
address these gaps in screening
sensitivity.
Microcalcifications on
mammogram
Masses not felt clinically
Core biopsy
• Main tool for establishing a proper
diagnosis and so quick treatment
thereafter.
• DOES NOT SPREAD CANCER OUT
Pre-op wire localization/ biopsy
MRI Breast
Treatments of breast cancer
Treatment of invasive breast
cancer
Preop evaluation:
Evaluation of extent locally in the breast and
regional nodes and distant sites (lung,
liver, bone)
Bilateral mammogram rule out other masses
Core biopsy
u/s to evaluate axillary lymph nodes +/FNAC of suspicious nodes.
Pre operative care
• Main issue is the psychological element
involved with mastectomy.
• Patient should be aware about what it
means and if necessary talk to patients
who had this procedure done.
• Show patients pictures in order not to be
shocked after the procedure.
Two parts of the operation
(breast options of treatment)
• Depends on size of tumor and patient
preference.
• Mastectomy vs breast conserving surgery
• Neoadjuvent chemotherapy to downsize
the tumor followed by conserving surgery
• Option of reconstruction immediate or
delayed.
Axillary staging
• Evidence of positive axillary lymph nodes
by fine needle aspiration cytology pre-op
ALND
• Otherwise all
should have SLNB
Sentinel lymph node biopsy
• Sentinel node is the first node draining a
particular portion of the body. It is the node
at highest risk for harboring occult
metastatic disease.
• Lymphatic mapping performed by injecting
a blue dye (1% isosulfan blue, or
technetium-labelled sulfer colloid (a
radioactive tracer material) or both,
adjacent to tumor.
• The tracer material progresses through
lymphatic channels to sentinel node which
may then be excised and tested for
evidence of metastatic disease using
frozen section.
• If the sentinel node has mets, a complete
axillary dissection is performed.
• If no mets, the patient may be spared
axillary dissection.
• Morbidity is less than ALND from this
procedure
• False –ve rate is ~3-5%
Gamma probe for detection of
SLNB
Blue node
SPECT/CT for sentinel imaging
• Single –photon emission computed
tomography.
• Nuclear med test uses radioactive
substance and special 3D camera to
localize the SLNB.
• Provides complimentary functional and
anatomical information.
Preop SPECT scan for SLNB
localization
Why SLNB?
• Up to 30% risk of lymphedema post ALND
and is up to 3%-10% post SLNB.
• It may be more common if radiation is
given after surgery.
Lymphoedema
• If the pathologist finds positive margins in
the tissue removed by breast-conserving
surgery, the surgeon may need to go back
and remove more tissue (re-excision).
• If the surgeon can't remove enough breast
tissue to get clear surgical margins, a
mastectomy may be needed.
Mastectomy scar versus conservative
surgery scars
Reconstructive surgeries: your
own muscle
Silicon implant
Postoperative complications
• Hematoma formation and infection: drain if
indicated.
• Seroma formation: frequent aspirations
may be required. A drain may have to be
inserted.
• Flap necrosis: excise and skin graft if the
defect is large.
Adjuvant Therapies
Chemotherapy : IV doses of
medications
• The use of systemic therapy is based on
age, tumor size and grade, nodal
involvement, and receptor status.
• Usually antracycline based
chemotherapy a cycle every 3
weeks for 6 cycles.
Radiotherapy
• VERY IMPORTANT
Inform the patient about RT post breast
conserving surgery.. It is a must!!
• If patient has a contraindication to
radiotherapy then can not perform breast
conserving surgery ( eg previous exposure
to RT).
• A dose of 50Gy is given to the whole
breast and then 10Gy is given to the
operative site as a boost (daily except
weekends).
Hormonal therapy- pill daily for
5-10 years
Rapid Diagnostic Breast Clinic
RDBC Structure
• The clinic provides rapid assessment and
diagnosis for patients with abnormality on a
mammogram, breast ultrasound or a clinical
finding that is highly suspicious of breast cancer.
• A dedicated nurse guides and supports each
patient through the assessment process.
RDBC Process
Patient presents to outside physician with a lump or screen detected abnormality.
Patient referred to KCCC Rapid Diagnostic Breast Clinic.
Patient triaged by Breast Care Specialist (BCS).
DAY 1: Patient meets with physician and BCS.
Further breast imaging performed along with biopsy if deemed necessary.
DAY 3: Pathology results available. Radiology reports available.
Patient meets with physician and BCS to review imaging and biopsy results.
Treatment planning organized.
Summary of the facts
• All women are at risk for breast cancer.
• You can have tests that can find breast
cancer early.
• You can learn to do BSE and check your
breasts at home.
• A clinical breast exam is an important way
to check for breast cancer.
• Mammogram can find breast cancers
when they are too small to feel.
FYI
For Kuwaitis above age of 40:
• Screening mammography centers:
• Shaikhan Alfarsi & Sherifa Alawadi center
in alsurra area
• South khaitan medical center
• Alnaeem medical center
• Alzahra medical center
• Aloqaila medical center
To book your mammogram
CALL
24620989
Between 7.30am-1.30pm
Thank you