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Most common site-specific cancer in women worlwide 2nd most common cause of cancer death in women 5th most common cause of death in women 8-12% lifetime risk of developing breast cancer
wards (20 surgical cases admitted for 2008) Majority of patients in Clinical Stage IIb, III and stage IV Majority of patients in Pathologic stage III Treatment is mostly surgical Poor follow-up
33%
Nipple changes (retractions, discharges) Ulceration/erythema of the skin of breasts Breast enlargement/asymmetry Axillary mass
Early Detection
2. 3. 4. 5.
the age of 20. (1-2 weeks after 1st day of menstruation. Clinical breast exam (CBE) starting the age of 20 and every 3-5 years thereafter Clinical breast exam at the age of 40 then yearly thereafter. Mammography starting at the age of 40 then yearly thereafter. Mammography at age 35 for high risk patients.
I
cancer
Screening mammography - women with no symptoms Diagnostic mammography - women with symptoms
Breast Ultrasound
adjunct to mammography Ductography* - for women with bloody nipple discharges MRI* - for high risk patients with dense breast during mammography
Surgery
Breast conserving surgery (lumpectomy, quadrantectomy) Mastectomy Modified radical mastectomy
Chemotherapy*
Adjuvant chemotherapy Neoadjuvant chemotherapy
postmenopausal
Treatment Pathways
History/PE Doubtful clinical breast exam, high risk, >40 years old Breast Ultrasound/Mammography (+) lesions (-) lesions
Hx and PE
>40 any size, high risk, <40 but mass 2cm or more Biopsy (FNAB/Excision or incision biopsy)
Malignant
Benign
Observe
High nuclear grade,high histologic grade, HER2 + may proceed with chemotherapy
(+) Chemotherapy
(+) Tamoxifen
(-)
Postmenopausal
Aromatase inhibitors
Adjuvant Chemotherapy
Radiotherapy Hormone Receptor (+) Postmenopausal Tamoxifen Aromatase inhibitors HER2/neu (+) tumors may be started with Herceptin
Chemotherapy
Radiotherapy
Hospice Care
yPredict prognosis and response to therapy yPredict more accurately the disease free and overall survival
rate than clinicopathologic staging yThese tumors tend to grow faster and recur more often yEGFr and HER2/neu overexpression signifies high nuclear grade and high proliferation aneuploidy yTrastuzumab(Herceptin) y52% decrease in breast cancer recurrence
yBRCA-2 y 85% lifetime risk of developing breast cancer yCancer prevention for BRCA mutation carriers y Prophylactic mastectomy y Prophylactic mastectomy and HRT y Intensive suveillance y Chemoprevention
BCS vs Mastectomy
y Factors why women choose mastectomy over BCS y Fear of recurrence in remaining breast y Fear of dying from breast cancer y High cost of radiation with BCS y Distance from radiation facility y Older women favor mastectomy
Chemotherapy regimen
y Node negative women y CMF y FAC y AC y Node positive women y FAC or CEF y AC +/- T y A CMF y CMF y EC