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Guidelines in management of breast cancer UK experience

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Guidelines in management of breast cancer UK experience Powered By Docstoc
					Guidelines in management of
breast cancer (UK experience)

     HAMDY ELMARAKBY MD
            FRCS
Breast Pain (cyclical or not)
• No mass, mild pain:
  - <35 years: reassure and discharge.
  - > 35 years: mammography
• No mass, moderate to severe pain:
  - < 35: ultrasound
  - > 35: mammography
• Good support bra night and day, reduce caffeine
  intake, discontinue smoking, low fat diet,
  change the type of contraceptive pills and
• Evening primrose capsules:
   - Gamolenic acid 240-300mg
   - 3-4 months at least
   - Danazol 100mg daily, assess after one month
      and continue for 6 months if response.
 Cystic disease ( fibrocystic or
 not)
• Palpable cysts, 7% of western women.
• U/S, Mammography according to the
  age group.
• Aspirate (free hand or ultrasound):
 - No blood, no residual lump, not re-
  accumulating: discharge
 - Rapidly recurrent, or blood: re-image,
  FNAC ?excision?
• Multidisciplinary meeting (MDM).
 Breast Cancer : Diagnosis
• Monday am clinic (new patient): one
   stop (triple assessment).
• Wednesday pm: multidisciplinary
   meeting (MDM).
 - Surgeons, Oncologist, Radiologist,
   Pathologist, breast care nurses,
   secretaries
• Thursday am: New follow ups
• Thursday pm: all other follow ups
   Diagnosis
• Breast lump, asymmetric thickening, nodularity, nipple
  discharge.

• Triple assessment: clinical examination, radiological
  (ultrasound, mammography), Biopsy( wide bore needle,
  FNAC).


• P value, U value, R value: 1-5(normal, benign, uncertain,
  suspicious, malignant).

• Any P3,U3, R3 should be biopsied.

• One stop clinic: patient will be given another appointment for
  the results if P3,U3,R3.

• FNAC is only used with too small or inaccessible lesions and
  with nipple discharge.

• All discordant results should be discussed in the MDM.
Ultrasound/Mammography
• Ultrasound: breast abnormalities in ages
  <35 years, however,
• It should not used in pain, and not as
  screening tool.
• Mammography:
    - Breast abnormalities in ages >35 years.
    - National screening programme >50
      years.
    - Early Screening (age < 50years,+family).
    - Nipple discharge.
    - Follow up in diagnosed breast cancer.
MRI

• Ill defined tumours/ breast
  conservative surgery.
• Multifocal disease?
• Assessment of the integrity of
  breast prosthesis?.
• Decision should be made at the
  MDM as mammography has
  taken over.
Excision biopsy

• Diagnostic uncertainty on core
  biopsy or FNAC.
• Lump >30mm in all age groups.
• Discuss and consider excision
  of all lumps in > 35 years even if
  P2,R2.
• MDM discretion
Breast Discharge
• Single duct:
• FNAC: performed by surgeons.
   - Benign (c2) or negative for blood:
     see 3 monthly for a year.
   - Uncertain (C3) or + ve for blood:
     consider surgery ( micro-
     dechoctomy <50 years, macro-
     dechoctomy>50 years).
• MDM
Breast Discharge, continued
• Multiduct:
  - Bilateral: benign (c2) or negative for blood,
    reassure and discharge.
  - Unilateral: same criteria /follow up 3 monthly
    for a year.
  - Uncertain (C3) or + ve for blood, or
    troublesome: consider mammmo dechoctomy
    after discussion in MDM.

• Consider hyper prolactinaemia or drug induced
   galactorhea if profuse bilateral and
   embarrassing.
 Other investigation tools

• All patients should have FBC, LFT,
  CXR and bilateral mammogram.
• No routine bone scan or liver US for
  operable breast cancer unless
  abnormal routine tests or if
  symptoms suggestive of metastasis.
Surgery

• D.C.I.S.
• Operable breast cancer.
• Locally advanced disease.
Non surgical treatment

•   Adjuvant chemotherapy.
•   Adjuvant hormone treatment.
•   Adjuvant Radiotherapy.
•   Neo-adjuvant Chemotherapy.
Male breast cancer

• <1% of breast cancer and < 1% of all
  male cancers.
• Guidelines are essentially the same
  as female breast cancer.
• Clinical outcome when matched for
  age, stage and treatment protocol
  are similar to females ( Perkins and
  Middleton BMJ 2003).
Surgery for early breast
cancer
• Non invasive breast cancer (DCIS):
   - No absolute consensus.
   - Lesions < 4cm: WLE with 1cm safety
     margin. No axillary surgery.
   - Lesions > 4cm or multifocal consider
   mastectomy.
   - Axillary node sampling if extensive multifocality
   (1-5% lymph node involvement) ( Dixon 1998)
   - DXT: beneficial
 - Hormonal treatment: less certain ( Lancet IBIS
   trial 2003).
• Lobular carcinoma in situ (LCIS): a marker lesion
   for increased risk of invasive cancer/close
   surveillance.
WLE
WLE+ Augmentation
Mammoplasty
  Invasive Breast Cancer
  (Early)
• Breast Conservative Tumour (BCT):
  solitary <3cm, or selected cases with >
  3cm in large breast (MDM).
• Contraindications:
  - multifocal,
  - recurrent disease after BCT,
  - patient choice,
  - tumour > 3cm,
  - centrally placed tumors, or
  - if DXT is contraindicated,
  - pregnancy,
  - age< 35 years( MDM).
Breast Conservative Surgery
(BCS)
• A cylinder of breast tissue from skin to
  deep fascia is removed.
• No skin is removed unless superficial
  tumor.
• Macroscopic radial margins should be at
  least 10-20mm and microscopic margins at
  least 5mm.
• Radiopaque clips: 1( anterior
  surface),2(medial surface), 3(inferior
  surface).
• Silk suture on tissues closest to nipple.
Breast conservative
surgery
What’s next
• Specimen x ray for all cases with a
  detectable mammographic abnormality.
• If close margin: immediate re-excision
  at same operation.
• 4 axillary node sampling if axillary
  clearance is not indicated.
• ER and PR status in all patients.
• Mark the cavity with 4 clips on the
  pectoral fascia for DXT( superior,
  inferior, medial and lateral).
 Treatment of axilla
• Incidence: 1%(DCIS),5%-28%(T1),
  48%(T2), 68%(T3), 88%(T4).
• Axillary sampling (4 node):
 - if clinically N0
• Axillary clearance: if N1 or +FNAC
  and if mastectomy is indicated for
  recurrent disease.
• Not indicated if previously treated
  with radiotherapy.
Locally advanced Breast
Cancer

• large cancer(T3-4), skin or muscle or
  chest wall infiltration, matted L.N.
• Full screen for metastasis( bone
  scan, liver US, possible CT chest).
• MDM: select cases for adjuvant
  chemotherapy and hormonal ttt
  (Cancer;98:1150-60, 2003).
 Locally advanced Breast
 Cancer
• Hormonal: slowly growing, ER PR+,
  unfit patients for chemotherapy.
• Chemotherapy: inflammatory
  carcinoma, ER, PR –ve, young
  patient <35.
• Value: down staging,
• Definitive surgery will entirely
  depend on the tumor response.
   Chemotherapy
• Adjuvant( in addition)/Neo-adjuvant (in
  advance/instead) of surgery.
• Details pathology: tumour size, grade,
  nodal, receptor status, margins of excision
  and the presence or absence of vascular or
  lymph-vascular invasion.
• Indications (risk factors): +ve nodes, grade
  2-3, size>2cm,vascular invasion and
  receptor –ve tumors.
• Anthracycline based e.g. 6 cycles of
  Epirubicin,5FU, Cyclophosphamide. Other
  combinations Epirubicin, Cyclophosphamide
  and Taxane.
 Chemotherapy continued
• HER2 receptor status is becoming
  increasingly important particularly in
  relapse patients who are candidates for
  Trastuzumab (Herceptin).
• The benefits of chemotherapy in
  postmenopausal patients is increasingly
  appreciated making the traditional
  classification of patients into pre and post
  menopausal less crucial.
• Chemotherapy is not routinely offered to
  patients>65years.
   Hormonal therapy
• All patients with estrogen/ progesterone
   receptors positive.
• Tamoxifen 20mg/day for 5 years.
• Exceptions: previous tamoxifen therapy or history of
  thrombo-embolism.

• Should not simultaneously prescribed with DXT for fear of
  increased risk of pulmonary fibrosis. (Radiother Oncol
  2002,Br J Cancer 2004).

• Should not simultaneously prescribed with chemotherapy
  as it reduce its effect and significantly increase the
  incidence of thromboembolism.

• ATTOM trial 5 more years of tamoxifen after finishing a 5
  year treatment. Provided that the patients are disease free
  and had a complete resection of tumors.
   Arimidex (Anastrozole)
• A non steroidal aromatase inhibitor.
• ATTAC trial suggests: it is stronger
  with better prognosis and lesser
  side effects than tamoxifen.
• Nevertheless more arthralgia and
  fractures complication (Lancet
  2005).
• Receptor +ve postmenopausal.
   Adjuvant Radiotherapy
• Post BCS: DXT is given to the breast and the
  lower axilla in the tangential glancing fields.

• DXT should be considered for all patients with
  completely excised DCIS who had undergone BCS.
• Only those with lesions <10mm should be
  discussed at the MDM.

• 4500-5000 cGY in 20-25 fractions daily. Options to
  give boost in younger patients.

• DXT to supraclav. L.N: Should be considered with
  4 or more pathologically involved axillary L.Ns,
  apical nodes involvement and with extra nodal
  spread of tumor.
Post-mastectomy Radiotherapy
 • Chest wall:
   - 4 or more pathologically involved axillary
      nodes,
   - primary tumor >5cm(large breast)
   - and tumor 3-5cm( small breast),
   - narrow deep margin <0.5cm,
   - evidence of lymph vascular invasion.
 • Irradiation to the axilla is only for those
   who have not had axillary clearance.
    Follow up
• Access to breast care nurse/unscheduled
  outpatient review and for post 5 years follow ups.

• Patients are seen for 5years in the breasts cancer
  follow up clinic starting from 2 weeks
  postoperative where the results are conducted.

• Alternating appointment every 3months between
  the oncologist and the surgeon for 2 years, then
  very 6 months for 3years.

• Clinical examination to the breast and the lymph
  nodes.
   Follow UP
• Mammography is requested annually for 5
  years.
• After 5 years if < 50years, arrange biennial
  mammography until 50years.
• if>50years then discharge to NHSBSP for
  3yearly screening.
• IF>70years self referral for 3yearly screening.
• All patients diagnosed with distant metastasis
  should stop mammography surveillance.
• Other investigations are only requested if
  symptoms develop e.g. back pain, lump, rash
  etc
Breast reconstruction

• Patients should be aware prior
  to surgery for the possibility of
  breast reconstruction.
• Primary? Delayed?
• All patients should be offered
  the opportunity to meet another
  patient who underwent BR.
Breast Reconstruction
Breast reconstruction
 Quality standards
• All patients with suspected breast
  cancer should be seen by specialist
  within 2 weeks of GP referral.
• More than 90% of GPs must receive
  feed back from the breast unit within
  one week of patients appointment.
• One stop clinic: Clinical, imaging,
  biopsy should be performed at the
  initial visit.
  Quality standards
• >90% of patients should be
  diagnosed preoperatively.
• <10% of patients should attend the
  hospital for more than one visit for
  diagnostic purposes.
• >90% of diagnosed patients should
  be admitted for surgery within 2
  weeks and 100% within 4 weeks.
• BCS, BCN, MDM are compulsory.
Outcome of breast cancer

• 60% of patients will develop some form of
  recurrence, 2/3(40%) will develop within 5
  years.

• 50% will eventually present with distant
  metastasis and die from the disease.

• Nottingham prognostic index (NPI):
  Grade(1-3)+ N Stage (N 0-2)(1-3)+ (0.2xsize
  of tumor in cm)
  Outcome of breast cancer

• No (negative axilla), N1 (low axilla},
  N2 (high axilla).
• Good (score<3.4)(80% 10 year
  survival ),moderate (score 3.4-
  5.4)(40% 10 year survival) , poor
  (score >5.4) (15%10 year survival).
• Example: 2cm,G2,N1= 0.4+2+2= 4.4
  =moderate
 Family history
• Genetic predisposition in 5-10%.
• However 15% of patients give family
  history.
• Pedigree analysis questionnaire and
  qualitative risk assessment will be
  made.
• Refer to regional genetic cancer
  clinic.
   Family History
• Risk factors: a close female relative had breast cancer <40,
  or had bilateral breast cancer or

• 2 close female had breast cancer < 60 or one had breast
  and the other had ovarian cancer or both had ovarian
  cancer.

• A male close relative had breast cancer at any age.

• A close relative denotes a first and second degree.

• Refer to regional cancer genetic clinic.

• Moderate and high risk female will have an annual clinical
  assessment and mammography starting from the age of 35-
  40 years.
• At 50 years they are discharged back to the NHSBSP
Thank you

				
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