BREAST CANCER CARE AT UIHC2 - iapasociety.org · Inflammatory Breast Cancer u Non-blanching...

10/2/17

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BREAST CARE AT UIHC Diana Besler, ARNP, DNP

Holden Comprehensive Cancer Center

University of Iowa River Landing

Breast Cancer Incidence

Ø  Breast cancer is the most frequently diagnosed cancer in women in the United States.

Ø  American Cancer Society estimates 252,710 new cases of invasive breast cancer will be diagnosed in the U.S., along with 63,410 of non-invasive cases in 2017.

Ø  2,470 new cases in men. Ø  In Iowa 2,300 female breast

cancers were estimated in 2017.

Cancer in Iowa 2017 College of Public Health

Demographics

Ø  One out of every eight women will be diagnosed with breast cancer in 2017.

Ø  Average age of breast cancer diagnosis in the general population is 62 years.

Ø  Highest rates are in Western countries (>100 cases per 100,000) and lowest are in Asian countries (10-15 cases per 100,000).

www.breastcancer.org

U.S. Breast Cancer Facts

Ø  As of March 2017, there are roughly 3.1 million women breast cancer survivors.

Ø  Woman’s risk of breast cancer nearly doubles if she has a first degree relative affected by breast cancer.

Ø  Nearly 85 % of breast cancers occur in women who have no family history of breast cancer.

Ø  Due to genetic mutations as a result of aging process

Ø  Environmental exposures

Ø  Most significant risk factors are female gender and aging.

Ø  About 5-10% of breast cancers can be linked to gene mutations.


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What Causes Cancer?

Involves multiple factors, some we know about, others we just don’t know. There is no single cause.

Most breast cancers occur sporadically (70 %), whereas the remaining occur due to genetic, familial or unknown causes.


What Causes Cancer

Genetic factors- Alterations in two types of genes important to cell growth can cause normal cells into cancerous cells.

Ø  Tumor suppressor genes- Turn off cell growth, stopping cancer cells to occur. These are known as BRCA 1 and BRCA 2, which manifest in developing breast cancer at an early age.


BRCA1-Associated Cancers

Ø  Lifetime risk for developing first cancer w/o intervention ~ 50% to 85%.

Ø  Second cancer between 40% to 60% and ovarian cancer 20% to 45%.

Ø  Females have increased risk of developing cervical, uterine, pancreatic and colon cancer

Ø  Males have increased risk of breast cancer, possibly pancreatic cancer.


BRCA2-Associated Cancers

Ø  Increased risk of pancreatic cancer, stomach cancer, gallbladder bile duct cancer, and melanoma.

Ø  Males at increase risk of prostate cancer

Ø  Accounts for ~ 6% of male breast cancers.


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Other Gene Mutations HER2

Ø  Oncogenes- Genes that turn on cell division and growth. If become damaged or defective, cell growth runs out of control.

Ø  Abnormalities in these genes can be contribute to breast cancer; however, they are not inherited.

Ø  One such gene is called HER2 Ø  Normally, HER2 receptors help

control how a healthy breast cell grows, divides and repairs itself.

Ø  About 25 % of breast cancers, the HER2 gene makes too many copies, or an overexpression causing cells to grow in an uncontrolled fashion. Known as HER2 positive.

Ø  HER2 breast cancers tend to grow faster.

American Cancer Society

Breast Anatomy

Ø  Composed mainly of connective tissue and fatty tissue.

Ø  15-20 milk forming lobes

Ø  Ducts carry milk from the lobes and eventually empty at the nipple.

Ø  Breast has no muscle tissue.

Ø  Pectoral muscle lie between the breast and ribs

What To Watch For

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Breast Mass NCCN Guidelines

Nipple Changes (Crusting)

Paget’s of the Breast Underlying Invasive Ductal Carcinoma

Early Paget’s Disease Advanced Paget’s Disease

Nipple Eczema

Ø  Treatment with topical steroid, Westcort 0.2 % ointment for 7-10 days. Patient returns for follow up, if persistent nipple crusting, refer to breast surgeon.

Ø  Diagnosis confirmed on punch biopsy.

Ø  May consider breast MRI.

Dirbas-Scott-Conner, Breast Surgical Techniques and Interdisciplinary Management, Springer, 2011

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Risk Factors Risk Factors

Modifiable Ø  Normal BMI, excess body fat converts to

estrogen

Ø  Minimal or no alcohol intake. Women should drink no more than one alcoholic drink a day.

Ø  Exercise most days of the week, moderate exercise. Strenuous exercise may negatively effect hormones estrogen and progesterone and increase cortisol(stress hormone).

Ø  Don’t smoke or quit smoking.

Ø  Know your breast density

Ø  Know your family history

Non-modifiable Ø  Family history

Ø  Breast density

Ø  Age

Ø  Menopause after 55 y o

Hartmann LC, Loprinzi CL, The Mayo Clinic Brast Cancer Book, 1 st ed Good Books, 2012, 61-73

Know Your Density Whole Breast Ultrasound (ABVS)

Breast Cancer Risk Tools

Gail Model Ø  https://www.cancer.gov/bcrisktoo

u  Epidemiologic, age, age of menarche, age of parity, biopsy history including h/o atypical ductal hyperplasia.

Tyrer-Cuzik (IBIS)International Breast Cancer Intervention Study

Ø  http://www.ems-trials.org/riskevaluator/

u  More expansive epidemiologic history, h/o OCP/hormone use, newer version includes breast density

u  More extensive family history also includes 2 nd degree relatives, ( grandparents/aunts/uncles)

u  Calculates risk of BRCA mutation

Copyright 2017, National Comprehensive Cancer Network

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Breast Cancer at the Molecular Level

Ø  Luminal A: Accounts for 45 % to 60 % of breast cancers. ER/PR + HER2 – Slow growing

Ø  Luminal B: Account for 10 % of breast cancers. ER/PR + HER2 + faster growing

Ø  HER2: Makes up 10 % of breast cancers. ER/PR – /HER2 +

Ø  Triple negative/basal-like: This category includes 10-15 % of breast cancers. They are ER/PR – HER2 –

Hartmann LC, Loprinzi CL, The Mayo Clinic Brast Cancer Book, 1 st ed Good Books, 2012, 48

Ductal Carcinoma in Situ or DCIS (Pre cancer/high-risk lesion)

Invasive Ductal Carcinoma Lobular Carcinoma

www.mayoclinic.org/diseases-conditions/invasive-lobular-carcinoma/.../con-20033968

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Inflammatory Breast Cancer

u  Non-blanching erythema, peau d’ orange appearance

u  Erythema must encompass 1/3 of the breast

Comparison of Symptoms in Mastitis and IBC

Uptodate 2017

Diagnosing Breast Cancer

Ø  Patient feels a breast lump or has an abnormal mammogram/breast ultrasound or MRI.

Ø  Proceed with breast biopsy.

Ø  Staging breast cancer:

Ø  Stage 0- Carcinoma in situ

Ø  Stage I- Tumor < 2 cm, no nodes involved

Ø  Stage II- Tumor 2 to 5 cm, may or may not involve nodes

Ø  Stage III- Locally advanced disease,

Ø  Stage IV- Distant metastases ( bone, liver, lung, brain).

Breast Cancer Diagnosis

Ø  Invasive vs non-invasive

Ø  Ductal breast cancers ~ 80 %, lobular lesser degree, harder to diagnose

Ø  Grade-Determined under the microscope, either 1, 2 or 3.

Ø  Staging- I-IV

Ø  Whether cancer has spread

Ø  Size of tumor

Ø  Lymph node involvement

Ø  Estrogen/Progesterone positive 2/3 are positive

Ø  HER2/neu status (Aggressiveness).

10/2/17 Dirbas-Scott-Conner, Breast Surgical Techniques and Interdisciplinary Management, Springer, 2011

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Adjuvant therapy

Tamoxifen: Ø  Anti-estrogen drug that works by attaching to estrogen receptors in hormone

positive breast cancers.

Ø  Taken for five years possibly up to 10 years, or switched to AI.

Ø  Can be used pre or post menopause.

Aromatase Inhibitors: Ø  Prevents aromatase enzymes from converting to sex hormones.

Ø  Useful only in post menopausal women, because premenopausal women have functioning ovaries, AI’s can’t reduce estrogen.

breastcancer.org

Mammography

Ø  Mammography allows for earlier breast cancer detection.

Ø  Mammograms miss 10 % - 15 % of breast cancers; although, considered the gold standard. New 3D (tomosynthesis) improves detection.

Ø  Mammograms detect masses and microcalcifications. Tiny white flecks of calcium.

Ø  For every 1,000 women, 100 will have call back, 10 need biopsy, 3 will have a cancer.


Mammography with 3D tomosynthesis

Ø  Clinical study by Skaane, P showed 27 % increase in cancer detection.

Ø  Another study by Gatto, S showed 50 % increase in cancer detection

Ø  In a retrospective observational study by Rose, S. there was a 37.5 % reduction in call backs.

Ø  Unfortunately, with extremely dense breasts decrease mammography sensitivity to 57 % compared to 90 + % in fatty breasts.

Ø  American Cancer Society recommend women continue screening mammograms as long as their overall health is good and they have a life expectancy of 10 years or longer.

NCCN, 2017 Breast Cancer updates from 2016 San Antonio Breast Cancer Symposium

Screening Guide

Age Women in their 20’s and 30’s, average risk.

Women ages 40-49, average risk.

Women ages 50-74, average risk.

Women age 75 and older, average risk.

Women of all ages, high risk

Recommendation Ø  SBE optional, clinical breast exam

every 3 years. No mammogram ** Ø  SBE optional, annual clinical breast

exam. Mammogram every year. Ø  SBE optional, annual clinical breast

exam. Mammogram every year. Ø  Regular screening as long as

individual is in good health. Ø  SBE recommended. Clinical breast

exam every 6-12 months. Annual mammogram. May consider earlier screening, MRI.

** Exception to children of parent diagnosed under 40, will consider earlier onset screening with MRI in their 20's

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Benign Masses/Conditions

Benign Masses Ø  Fibroadenoma

Ø  Hamartoma

Ø  Phyllodes

Ø  Breast cysts, simple/complex

Ø  PASH (pseudoadenomatous stromal hyperplasia)

Ø  Radial Scar

Benign conditions Ø  Atypical Ductal Hyperplasia

Ø  Atypical lobular Hyperplasia

Ø  Lobular carcinoma in situ

Ø  Papilloma- Refer to breast surgeon

Ø  Mastitis

Ø  Fibrocystic Changes

Ø  Breast Pain/Gynecomastia

Ø  Mondor’s Disease

Non Cancerous Conditions

Ø  Fluid-filled lumps vary from tiny to egg size. Occur in 7 % of all women, most commonly seen in middle age women (40-50 yo). Incidence decreases after menopause, unless on HRT. Consider thyroid.

Ø  Fibrocystic changes- Nodularity or tissue thickening, pain and occasional nipple discharge, often associated with a women’s period.

Ø  Fibroadenoma-Solid, round, freely moveable, rubbery lump that often occurs mostly during reproductive years. More oval shaped on ultrasound. Looks longer than taller.

Ø  Infections-Skin of the breast will be red, warm, tender to the touch, may or may not feel a lump. (Not to be confused with inflammatory breast cancer).


Mondor’s Superficial Thrombophlebitis

Ø  Phlebitis of the thoracoepigastric vein. Seen in lactation or post op

Ø  Palpable, visible, tender cord along upper quadrants

Ø  Ultrasound may be helpful in confirming diagnosis

Ø  Treatment self-limited, reassurance

Ø  Can use anti-inflammatories if necessary


Nipple Discharge

Common. Accounts for 7 % of breast related symptoms.

~50-80 % of women will have nipple discharge at some point in their life.

Evaluation need to distinguish between physiologic vs pathologic


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Nipple Discharge

Physiologic Ø  Typically not spontaneous

Ø  Ranges in color including white(galactorrhea), tan and green.

Ø  Usually bilateral

Ø  Emanates from multiple ducts

Ø  Manipulation can initiate discharge in a healthy breast

Remedy Ø  Increased neurohormone

response from nipple stimulation decreases dopamine level, increasing prolactin level

Ø  Once pathologic caused eliminated Ø  Avoid checking or squeezing.

Ø  Well supporting bra

Ø  Shower water to back/avoid foreplay


Pathologic Nipple Discharge

Ø  Serous or bloody is worrisome for breast carcinoma Ø  Typically unilateral and involves a single duct Ø  Usually spontaneous

Ø  Caused by prolactinomas of the pituitary. Ø  Hypothyroid- hyperprolactinemia secondary to increased TSH. Ø  Endocrine related discharge is commonly milky and copious.

Ø  Majority will have benign disease: only ~ 11 % have carcinoma Ø  Most common etiologies include:

Ø  Intradcutal papilloma lesions ( 57 %).

Ø  Ductal ectasia or fibrocystic changes (32 %)

Ø  Inflammatory process such as abscess ( 3 %)


Work up for Pathologic Discharge

Ø  Spontaneous, Bilateral, Copious, Milky Ø  Endocrine work-up including TSH and prolactin

Ø  Spontaneous, Unilateral, Straw colored or bloody Ø  Diagnostic Mammogram/sonogram Ø  If abnormal, stereotactic or excisional biopsy Ø  Treat based on pathologic findings

Ø  Non-Spontaneous, Milky, Green, Tan or Gray Ø  Guaiac test Ø  Nipple smear for cytology

Ø  Patient teaching to abstain from checking Ø  Observe

Short term follow-up 3 months, 6 months if needed.


Breast Pain

Ø  One of the most common conditions second to breast mass. Can be frustrating for patient and provider

Ø  Up to 70 % of women under 55 years of age experience breast pain

Ø  Cyclical mastalgia Ø  Predictable pattern a/w menses

Ø  Non-cyclical mastalgia Ø  Constant/intermittent, not a/w menses

Ø  Chest wall pain/MSK

Ø  Tietze syndrome (costochondritis)


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Breast Pain

Ø  Thorough PE since ~ 18 % of women with breast cancer report focalized pain followed by detection of a lump

Ø  Mammography and/or targeted ultrasound should be considered for some patients

Ø  Sedentary lifestyle reported in 80 % of women with mastalgia, for them, increasing exercise levels may improve chronic pain via release of endorphins

Ø  Consider Thoracic Outlet Syndrome http://www.mayoclinic.org/diseases-conditions/thoracic-outlet-syndrome/home/ovc-20237878

Treating Breast Pain

Ø  Well supporting bra with proper bra fitting

Ø  Eliminate or reduce methylxanthines (coffee, tea, chocolate, cola beverages) or nicotine

Ø  Vitamin therapy, vitamin E 400 IU am/pm. Can be oral or topical

Ø  Organic ground flax seed, 2 tablespoons per day

Ø  Include iodine 150 mcg with selenium 70 mcg if taking a MVI. I recommend Nature Made brand vitamins.

Ø  OCP’s, bromocriptine


Speaking of Nature Made….. Infectious and Inflammatory Breast Disease

Ø  Abscess Ø  Treated by surgical drainage,~ 60-70% resolve when surgically drained

Ø  Always get a mammogram ~ one month after symptoms resolve to ensure no mass/cancer

Ø  Cellulits, mastitis Ø  Usually lactational-occurs in 2 to 10 % of breastfeeding woman. Can occur post

menopause

Ø  Treat with 10-14 day course of antibiotics to cover Staphylococcus and Streptococcus. Per John’s Hopkins Dicloxacillin 500 mg QID (preferred for breast feeding, no MRSA coverage), Flucloxacillin 500 mg QID, Amoxicillin/clavulanate 875/125 mg BID (covers MRSA), Cephalexin 500 mg QID. Beta-lactam allergy: Clarithromycin 500 mg BID. MRSA coverage: Clindamycin 300 mg TID/QID. TMP/SMX BID 10-14 days.

www.cancer.org/ John"s Hopkins antibiotic guide

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Ductal ectasia

Ø  Common in women over 50. Common in menopause, can happen after menopause

Ø  Occurs when a breast duct widens and its’ walls thicken, leading to blockage and fluid build-up

Ø  May cause a sticky green or black nipple discharge, which is often thick

Ø  Nipple and nearby tissue may be tender and red Ø  Nipple may be pulled inward

Ø  Treatment Ø  Self limiting, may resolve spontaneously with warm compresses

Ø  Antibiotics such as Keflex 500 mg bid to qid depending on severity

Ø  Refer to breast surgeon if symptoms persist

Gynecomastia

Ø  Enlarged disk-like glandular tissue. Can be painful

Ø  Order diagnostic mammogram-will see “flame shaped” area of increased density

Ø  Palpable mass, consider fine needle aspiration

Ø  Distinguish between pseudogynecomastia and breast cancer. Male breast cancer thought to be caused by estrogen excess and androgen deficiency

Ø  Strongest genetic link to male breast cancer is BRCA 2

Ø  Greater than 40 % male breast cancer presents in stage III or IV


Ø  Most common cause in adult men include:

Ø  Pubertal gynecomastia that does not resolve -25 %

Ø  Drugs- 10 to 25 % spironolactone, ketoconazole, Cimetidine, Finasteride

Ø  Unknown causes -25 %

Ø  8% cirrhosis or malnutrition

Ø  10 % testicular-failure (hypogonadism)

Ø  1 to 4 % caused by testicular tumors, gonadotropin deficiency, renal failure and hyperthyroidism

Ø  Contact from estrogenic vaginal creams

Ø  Antibalding medication

Ø  Recreational drugs like marijuana and alcohol


Treating Gynecomastia

Ø  Once breast cancer has been ruled out and the etiology has been determined, consider appropriate treatment.

Ø  Discontinue offending agent such as finasteride to see if gynecomastia improves to confirm drug related cause

Ø  Discontinue recreational drugs

Ø  Tamoxifen, an estrogen antagonist with up to 80 % of patients report partial or complete resolution.

Ø  Danazol, a synthetic derivative of testosterone inhibits pituitary secretion of LH/FSH- decreasing estrogen production from testicles.

Ø  If medical therapy is unsuccessful, refer to breast/plastic surgeon

Ø  Consider referral to endocrinologist Dirbas-Scott-Conner, Breast Surgical Techniques and Interdisciplinary Management, Springer, 2011

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