Slide 1

DR. A. AKHATOR FWACS, FICS SENIOR LECTURER DELSU CONSULTANT SURGEON DELSUTH Slide 2 1. Breast cancer is the most common cancer in women in Nigeria 2. Breast cancer is the most common cause of cancer related deaths 3. Breast cancer commonly present as painful breast lump 4. Prognosis of breast cancer is related to the size of the breast tumor 5. Trastuzumab (Herceptin R ) is treatment for ER/PR positive tumor Slide 3 Realize the burden of breast cancer in our environment The importance of early diagnosis in management of breast cancer Evaluate breast cancer symptoms and recommend appropriate management Slide 4 Slide 5 BREAST Slide 6 Slide 7 Breast cancer malignant neoplasm arising in the breast. Most common cancer in women worldwide. Incidence in Nigeria is 33/100,000 Incidence in males 1-9% of cases Peak age 42 years 78% locally advanced disease 22% metastatic disease Slide 8 APPROXIMATELY EVERY 3 MINUTES A WOMAN IS DIAGNOSED WITH BREAST CANCER APPROXIMATELY EVERY 12 MINUTES A WOMAN DIES FROM BREAST CANCER INCIDENCE INCREASING 5%/YEAR IN DEVELOPING COUNTRIES A REVIEW 1991 33% ADVANCED DISEASE IN DEVELOPED COUNTRIES 2007 60-80% ADVANCED DISEASE IN DEVELOPING COUNTRIES Slide 9 IN THE UK 2009 NEW CASES - 38,212 FEMALES, 250 MALES SECOND COMMONEST CANCER DEATHS IN US 211, 240 NEW CASES EXPECTED IN WOMEN 1,690 NEW CASES IN MEN African-American women have a lower incidence but higher mortality They also have higher risk for triple-negative tumours INCIDENCE 128.6/100,000 POPULATION Life time risk of 1 in 8 women Slide 10 Family History Lifestyle Personal History Slide 11 Mother, sister, or daughter has developed breast cancer before menopause 3 x. If two or more close relatives (e.g., cousins, aunts, grandmothers) have/had breast cancer. Mutations in genes BRCA1 and BRCA2 increase one's susceptibility to breast cancer. Slide 12 SHARED GENETIC MAKEUP SHARED LIFESTYLE SIMILAR ENVIRONMENTAL EXPOSURE 5-10% CAUSED BY INHERITED GENETICS Slide 13 Previous history of breast cancer Previous history of benign breast disease Menarche CURE RATES FOR BREAST CANCER 5 year cure rates of >90% obtainable for early tumours, < 30% for late tumours Slide 25 Stage 0 93% Stage I 88% Stage IIA 81% Stage IIB 74% Stage IIIA 67% Stage IIIB 41% Stage IIIC 49% Stage IV 15% Slide 26 Scars of treatment/no breast Younger survivors face Emotional stresses Trouble with social functioning Chemotherapy induced early menopause Sexual difficulties Slide 27 ASYMPTOMATIC PATIENT SCREENING BSE CBE Mammography MRI SYMPTOMATIC PATIENT Clinical evaluation Diagnostic investigations Slide 28 Slide 29 1. It is simple and easy to perform. 2. It is convenient and requires little time. 3. It is private. 4. It involves no medical cost 5. It is safe and non-invasive. 6. It requires no specific equipment. Slide 30 Pamphlets and leaflets. Instructional videos. Demonstrations and personal instructions. Slide 31 Breast self examination monthly Understand the breast and look for changes 1. Development of a lump. 2. Swelling. 3. Skin irritation or dimpling. 4. Nipple pain or retraction. 5. Redness or scaliness of the nipple or breast skin. 6. Discharge - other than milk. Standing and lying Slide 32 The best time to do breast self-exam is right after her period, when breasts are not tender or swollen. If she does not have regular periods or sometimes skip a month, do it on the same day every month. Slide 33 BREAST EXAM BY DOCTOR (CBE) EVERY 3 YRS BETWEEN 20-39YRS; YEARLY AFTER 40YRS, before mammogram POOR SENSITIVITY - 54% HIGH SPECIFITY 94% CBE-detected tumours has 70% survival Slide 34 XRAY OF THE BREAST (MAMMOGRAM) YEARLY AFTER 40 YRS Mammography-detected tumours has 90% survival Mammography increased detection of DCIS from 1% to 21% Regular screening by mammography and CBE decrease mortality by 25 30% in women 50years or older Slide 35 TRIPLE ASSESSMENT 1. CLINICAL EVALUATION 2. IMAGING 3. HISTOCYTOLOGY Slide 36 History Progression of symptoms Risk factors for breast cancer Treatment to date Physical examination Local systemic Slide 37 Breast lumps painless Swelling of the breast Nipple discharge blood stained Retraction of the nipple Changes in the skin of the breast Breast or nipple pain Signs of spread Slide 38 Slide 39 Slide 40 Slide 41 Slide 42 Slide 43 Slide 44 Slide 45 Slide 46 Slide 47 Slide 48 Slide 49 Breast scan Mammogram Digital mammogram Computer aided diagnosis (CAD) MRI OTHERS Thermography Scintimammography Tomosynthesis (3D Mammography) Slide 50 TYPES OF BIOPSY TECHNIQUE FNAC Core Needle Vacuum assisted Open biopsy Incisional excisional Slide 51 SURGERY 1. Mastectomy + reconstruction 2. BCS HORMONAL THERAPY CHEMOTHERAPY TARGETED THERAPY RADIOTHERAPY Slide 52 Large tumors Centrally located tumors Large tumors cf size of breast Multicentric tumor mammogram Previous radiotherapy Patients preference Slide 53 Simple mastectomy + SLND Skin-sparing mastectomy Nipple-sparing mastectomy Modified Radical mastectomy Breast reconstruction/breast form Radiotherapy after mastectomy 1. Large tumors 5cm or larger 2. Deep seated tumors 3. 4 or more positive lymph nodes Slide 54 BCS + RT = BCT 75% Px in developed countries Tumor control rate of 80-90% 5 year survival rate 70-88% Local recurrence rate 2-10% Without RT 15-40% TYPES OF BCS Lumpectomy WLE QUART Slide 55 1. Very small breast 2. Very large breast 3. Advanced/high grade disease 4. Lactating breast/pregnancy 5. Multicentric disease 6. Contralateral disease 7. Previous RT 8. Central tumors 9. Multiple tumors 10. Risk for 2 nd tumor Slide 56 BCS is considered without radiotherapy if all of the following are present 1. Patients aged 70 years or older 2. Tumor is 142 new cases presented to breast clinic (2008 -2009) 20 Were Breast Cancer (14.08%) ONLY 1 CAME WITH EARLY DISEASE (5%) 62% PRESENT > 3 months after noticing symptoms WHY ARE THEY COMING LATE? Slide 63 Ignorance Lack of facilities Fear of diagnosis Fear of the treatment Alternative treatment options Delay in referrals from peripheral centres NO SCREENING PROGRAM Slide 64 Slide 65 Slide 66 Slide 67 Slide 68 NMA active in promoting awareness of cancer especially breast cancer NHIS Include cancer screening as part of their healthcare provision Provision of facilities radiotherapy Short trigger for referral of breast complaints Slide 69 Breast cancer is here with us. Patients are presenting with advanced breast disease Early breast cancer has >90% survival rate Late breast cancer has < 30% survival rate It is our responsibility to get these patients to present earlier BSE CBE Mammogram Slide 70 Akhator A, Oside CP. Breast diseases in Warri. African J of Trop Med & Bio. Res 2010. Akhator A. Clinicopathological study of breast cancer in Eku. The Nigerian J of Clinical Practice 2008 Adebamowo CA, Ajayi OO. Breast cancer in Nigeria. West Afr J Med 2000 Guideline implementation for breast health care in low and medium income countries. The Breast health global initiative 2007 Scottish intercollegiate guidelines network management of breast cancer in women. Slide 71 Disease Control priorities project Controlling Cancers in developing countries. April 2007 National Institute for Health and Clinical Excellence Guidelines Early and Locally advanced breast. February 2009. National Institute for Health and Clinical Excellence Guidelines Advanced breast cancer Cancer screening in United States, 2007; A review of current Guidelines, practices, and prospects Slide 72 Slide 73 1. Breast cancer patients present commonly to breast clinic with early disease in Warri 2. The prognosis of breast cancer is related to the grade of the tumor 3. Hormone receptor assay is essential in the management of breast cancer. 4. BSE is the most widely recommended method for screening breast cancer 5. Breast conservative surgery is the best treatment for stage III disease.