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Breast cancer
1. BREAST CANCER
Worldwide incidence in females*
Western
Europe 67.4
Eastern
Europe 36.0
Japan 28.6
Australia/
New Zealand 71.7
South Central
Asia 21.2
Northern
Africa 25.0
ARGENTINA Southern
Africa 31.5
Central
America 25.5
North
America 86.3
*Incidence per 100,000 population.
Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
2. NEOPLASIA DE MAMA 2011
1.1 MILLONES DE CASOS NUEVOS DIAGNOSTICADOS/AÑO
10 % DE TODOS LOS NUEVOS CA EN EL MUNDO
410.000 DEFUNCIONES ANUALES
REPRESENTAN EL 1,6 % DE TODAS LAS DEFUNCIONES ANUALES DE
MUJERES.
ES UN PROBLEMA DE SALUD URGENTE EN REGIONES DE ALTOS
RECURSOS Y ESTA AUMENTANDO EN LAS REGIONES DE BAJOS
RECURSOS HASTA EN UN 5 %. (OMS)
A PESAR DEL AUMENTO DE CASOS DIAGNOSTICADOS, EL NUMERO DE
MUERTES ES MENOR GRACIAS A DETECCION TEMPRANA Y MEJORAS
EN LOS TRATAMIENTOS.
3. BREAST CANCER
5-year relative survival rates by race
87
98
White
78
23 All Stages
Localized
71 Regional
African 89 Distant
American 62
14
0 20 40 60 80 100 120
% Surviving 5 Years
Landis SH, et al. CA Cancer J Clin. 1999;49:8-31.
4. BREAST CANCER
Natural history
Highly variable in different patients
Relatively slow growth rate
Median survival without treatment: 2.8 yrs
Generally present several years by time of
diagnosis
Long preclinical period enables early
detection
Henderson IC. American Cancer Society Textbook of Clinical Oncology. 1995;198-219.
5.
6. BREAST CANCER
Risk factors
Age
Family history of breast cancer
Prior personal history of breast cancer
Increased estrogen exposure
– Early menarche
– Late menopause
– Hormone replacement therapy/oral contraceptives
Nulliparity
1st pregnancy after age 30
Diet and lifestyle (obesity, excessive alcohol consumption)
Radiation exposure before age 40
Prior benign or premalignant breast changes
– In situ cancer
– Atypical hyperplasia
– Radial scar
Henderson IC. American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;198-219.
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
Trichopoulos D, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;231-257.
7. BREAST CANCER
Screening
Breast self-examination Examination Mammography—the
by physician only modality shown
to decrease mortality
11. BREAST CANCER
Goals of mammography screening
Earlier diagnosis in asymptomatic individuals
Reduction of mortality due to detection at earlier stage
Age Mortality Reduction (%)
40-49 17% 15 years post-screening
50-69 25%-30% 10-12 years post-screening
70+ Insufficient data
PDQ: Screening for breast cancer for health professionals:
http://Cancernetnci.nih.gov/. Accessed November 28, 1999.
12. BREAST CANCER
Screening (high-risk)
Annual mammogram, beginning 5 yrs before age
of youngest affected relative at time of diagnosis
– High familial risk
– BRCA 1/2-positive
Tripathy D, Henderson IC. Current Cancer Therapeutics. 3rd ed. 1999;123-129.
13. BREAST CANCER
Screening mammography
Reduces mortality by 26% in women
aged 50-74
Supports view that early diagnosis and
treatment can prevent metastasis
ACS recommends
– 1st screening mammography by age 40
– Mammography every 1 to 2 years between
the ages of 40 and 49
– Mammography annually thereafter
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
Fink DJ, Mettlin CJ. American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;128-193.
14. BREAST CANCER
Signs and symptoms at presentation
Mass or pain
in the axilla
Palpable mass
Thickening
Pain
Nipple discharge
Nipple retraction
Edema or erythema
of the skin
15. BREAST CANCER
Anatomical site
SUPERO EXTERNO
Upper inner
Upper outer
Nipple
Axillary tail
Central portion
Lower inner
Lower outer
RIGHT
21. CÁNCER DE MAMA
FACTORES A TENER EN CUENTA AL DIAGNOSTICO INICIAL:
• EDAD
• ESTADO HORMONAL (PRE/POST)
• DIAMETRO TUMORAL (T)
• ESTADO GANGLIONAR (N)
• DETERMINACION DE RECEPTORES HORMONALES
• DETERMINACION DE HER 2
• GRADO HISTOLOGICO/PERMEACION VASCULAR
• PS
22. BREAST CANCER
Biopsy techniques for palpable and
mammographically detected masses
Excisional biopsy (usually outpatient)
– Tumor size and histologic diagnosis
Core-cutting needle biopsy (in-office)
– Histologic diagnosis
Fine-needle aspiration (in-office)
– Cytologic diagnosis
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
23. BREAST CANCER
Pathology
Non-invasive carcinoma in situ
– Ductal carcinoma in situ (DCIS)
– Lobular carcinoma in situ (LCIS)
Invasive carcinoma
– Infiltrating ductal or lobular carcinoma
– Medullary, mucinous, and tubular carcinomas
Uncommon tumors
– Inflammatory carcinoma
– Paget’s disease
Dollinger M, et al. Everyone’s Guide to Cancer Therapy. 1997;356-384.
24. BREAST CANCER
Pathology: Non-invasive DCIS & LCIS
DCIS LCIS
Abnormal mammogram Microscopic characterization
on biopsy
Clustered microcalcifications Solid proliferation of small
or non-palpable masses cells with uniform round to
oval nuclei
30% risk of invasive cancer 37% chance of subsequent
at 10 years at or near invasive cancer
original biopsy site
DCIS – ductal carcinoma in situ.
LCIS – lobular carcinoma in situ.
Harris J, et al. Cancer: Principles & Practice of Chemotherapy. 5th ed. 1997;1557-1616.
Love S, Barsky SH. Cancer Treatment. 4th ed. 1995;337-340.
25. BREAST CANCER
Incidence of major histologic types
Percent of all invasive carcinomas
80%
10%
5%
Infiltrating Lobular Medullary
Hendersn IC. American Cancer Society Textbook & Clinical Oncology. 1995;198-219.
29. BREAST CANCER
TNM stage grouping
Stage 0 Tis N0 M0
Stage I T1* N0 M0
Stage IIA T0 N1 M0
T1* N1** M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0, T1,* T2 N2 M0
T3 N1, N2 M0
Stage IIIB T4 Any N M0
Any T N3 M0
Stage IV Any T Any N M1
* Note: T1 includes T1 mic.
** Note: The prognosis of patients with N1a is similar to that of patients with pN0.
Used with the permission of the American Joint Committee on Cancer (AJCC®), Chicago, Illinois.
The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997)
published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
30. BREAST CANCER
Tumor definitions
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ,
or Paget’s disease of the nipple with no tumor
T1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion more than 0.1 cm or less in greatest dimension
T1a Tumor more than 0.1 cm but not more than 0.5 cm in greatest dimension
T1b Tumor more than 0.5 cm but not more than 1 cm in greatest dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest dimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension
T3 Tumor more than 5 cm in greatest dimension
T4 Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below
T4a Extension to chest wall
T4b Edema (including peau d’orange) or ulceration of the skin of the breast
or satellite skin nodules confined to the same breast
T4c Both (T4a and T4b)
T4d Inflammatory carcinoma
Used with the permission of the American Joint Committee on Cancer (AJCC®), Chicago, Illinois.
The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997)
published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
31. BREAST CANCER
Stage I
T1 N0 M0 T1a: T 0.5 cm
T1b: 0.5 cm < T 1 cm
T1c: 1 cm < T 2 cm
T1
T 2 cm
N0 = no regional lymph node metastasis
M0 = no distant metastasis
32. BREAST CANCER
Stage IIA
T0
T1 } N1 M0 T2 N0 M0
T0 No evidence
T2
of tumor
2 cm < T < 5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s)
M0 = no distant metastasis
33. BREAST CANCER
Stage IIB
T2 N1 M0 T3 N0 M0
T3
T > 5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b
M0 = no distant metastasis
34. BREAST CANCER
Stage IIIA T0
T1
N2 M0
T3 N1 M0 T2
T3
Metastasis to ipsilateral axillary lymph node(s)
N1 = movable
N2 = fixed to one another or to other structures
M0 = no distant metastasis
35. BREAST CANCER
Stage IIIB
T4 any N M0 Any T N3 M0
T4
Tumor of any size
with direct extension
to chest wall or skin
T4d = inflammatory
carcinoma
N3 = metastasis to ipsilateral internal mammary lymph node(s)
M0 = no distant metastasis
36. BREAST CANCER
Stage IV
Any T any N M1
M1 = distant metastasis (including metastases to ipsilateral supraclavicular,
cervical, or contralateral internal mammary lymph nodes)
37. BREAST CANCER
5-year survival as function of the number
of positive axillary lymph nodes
80%
60%
5-Year Survival
40%
20%
0%
0 1 2 3 4 5 6-10 11-15 16-20 >20
Number of Positive Nodes
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
38. CÁNCER DE MAMA
MOMENTOS PARA TRATAMIENTO
DIAGNOSTICO:
INICIAL METASTASICO
PROGRESION RECAIDO
RECURRENTE
TRATAMIENTO: “MEDICINA BASADA EN LA
EVIDENCIA”
39. CÁNCER DE MAMA
FACTORES A TENER EN CUENTA AL DIAGNOSTICO INICIAL:
• EDAD
• ESTADO HORMONAL (PRE/POST)
• DIAMETRO TUMORAL (T)
• ESTADO GANGLIONAR (N)
• DETERMINACION DE RECEPTORES HORMONALES
• DETERMINACION DE HER 2
• GRADO HISTOLOGICO/PERMEACION VASCULAR
• PS
40. NEOPLASIA DE MAMA 2011
NORMAS DE LA OMS
1)DETECCION TEMPRANA Y ACCESO A LA ATENCION
2)DIAGNOSTICO Y PATOLOGIA
3)TRATAMIENTO Y ASIGNACION DE RECURSOS
4)SISTEMAS DE ATENCION DE SALUD Y POLITICA
PUBLICA.
PILARES DEL TRATAMIENTO
CIRUGIA
RADIOTERAPIA
QUIMOTERAPIA
MEDICINA PALIATIVA
INVESTIGACION CLINICA!!
41. HORMONOTERAPIA
MODULADORES SELECTIVOS DE RECEPTOR
DE ESTROGENO:
TAMOXIFENO
TAROMIFENO
ABLACION OVARICA:
ANALOGOS LHR GOSERELIN/LEUPROLIDE
OOFORECTOMIA
PROGESTAGENOS:
ACETATO DE MEGESTROL
ACETATO DE MEDROXIPROGESTERONA
43. ONCOLOGY
Cancer biology
Tumor growth and detection
1012
cancer cells
Number of
109 Diagnostic
threshold
(1cm)
time
Undetectable Detectable
cancer cancer
Limit of Host
clinical death
detection
44. ONCOLOGY
Principles of chemotherapy
Action sites of cytotoxic agents
Antibiotics
Antimetabolites
S
(2-6h)
G2
(2-32h) Vinca alkaloids
M Mitotic inhibitors
(0.5-2h)
Taxoids
Alkylating agents
G1
Cell cycle level (2- h)
G0
45. ONCOLOGY
Principles of chemotherapy
Action sites of cytotoxic agents
DNA synthesis
Antimetabolites
DNA Alkylating agents
DNA transcription DNA duplication
Mitosis
Intercalating agents
Cellular level
Spindle poisons
49. ONCOLOGY
Principles of chemotherapy
Aim of combination therapy
INCREASED EFFICACY
ACTIVITY SAFETY
Different mechanisms of action Compatible side effects
Different mechanisms of resistance
50. ONCOLOGY
Principles of chemotherapy
Side effects of chemotherapy
Alopecia
Mucositis
Pulmonary fibrosis
Nausea/vomiting
Cardiotoxicity
Diarrhea
Cystitis Local reaction
Sterility Renal failure
Myalgia
Myelosuppression
Neuropathy
Phlebitis
