3. Background
Excluding cancers of the skin, breast cancer is
the most common type of cancer in women in
the United States.
Accounts for one of every three cancer diagnoses.
An estimated 174,480 new invasive cases of
breast cancer were expected to occur among
women in the United States during 2007.
About 2,030 new male cases of breast cancer
were expected in 2007.
4. Background
The incidence of breast cancer rises after age
40.
highest incidence (approximately 80% of invasive
cases) occurs in women over age 50.
62,030 new cases of in situ breast cancer were
expected to occur among women during
2007.
Approximately 88% will be classified as ductal
carcinoma in situ (DCIS).
5. Background
2007 - estimated 40,910 deaths (40,460
women, 450 men)
Ranks second among cancer deaths in
women.
Mortality rates steadily decreased since 1990
Larger decrease in women under 50
Due to combination of earlier detection &
improved treatment
7. Risk Factors
Age—more prevalent in older women
Exposure to natural estrogens
First childbirth after age 30
Age at menopause
Obesity—estrogens stored in body fat
Affluence
High-fat diet
Alcohol consumption
Genetics/family history
8. Reducing Risk
Having children at early age
Breast feeding
Healthy body weight
Exercise
Anti-estrogens
9. Symptoms
New lump or mass
painless, hard, uneven edges
sometimes tender, soft, or rounded
Swelling
Skin irritation or dimpling
Nipple pain or nipple turning inward
Redness or scaliness of the nipple or breast skin
Nipple discharge (other than milk)
A lump in the underarm area
10. Breast Anatomy
Breast
Made up of milk-producing glands
Supported and attached to the chest wall by ligaments
Rests on pectoralis major muscle
No muscle tissue
Layer of fat surrounds the glands and extends
throughout breast
Three major hormones affect the breast
Estrogen, progesterone, and prolactin
12. Breast Anatomy
Breast contains 15–20 lobes
Fat covers the lobes and shapes the breast
Lobules fill each lobe
Sacs at the end of
lobules produce milk
Ducts deliver milk to the
nipple
13. Anatomy – the lymphatic
system
Important to know if cancer has spread to the
lymph nodes
The more nodes involved, the more likely it is
that the cancer may involve other organs.
Affects treatment plan.
14. Anatomy – the lymphatic
system
Most lymphatic vessels
in the breast connect to
lymph nodes under the
arm (axillary)
•Also internal mammary
nodes
•Supraclavicular or
infraclavicular nodes
15. Types of Breast Cancer
The earliest form of the disease is ductal
carcinoma in situ,
comprises about 15-20% of all breast cancers and
develops solely in the milk ducts.
Invasive ductal carcinoma,
develops from ductal carcinoma in situ,
spreads through the duct walls, and
invades the breast tissue.
Most common – 70-80% of cases
16. Types of Breast Cancer
cont’d.
Cancer that begins in the lobes or lobules is
called lobular carcinoma.
more likely to be found in both breasts.
accounts for 10–15% of invasive breast
cancers.
Both ductal and lobular carcinomas can be
either in situ, or self-contained; or infiltrating,
meaning penetrating the wall of the duct or
lobe and spreading to adjacent tissue.
17. Types of Breast Cancer
cont’d.
Less common types of breast cancer include the following:
Inflammatory
Medullary carcinoma (originates in central breast tissue)
Mucinous carcinoma (invasive; usually occurs in
postmenopausal women)
Paget disease of the nipple
Phyllodes tumor (tumor with a leaf-like appearance that
extends into the ducts; rarely metastasizes) and
Tubular carcinoma (small tumor that is often undetectable
by palpation)
18. Inflammatory Carcinoma
frequently involves entire breast
characterized by reddened skin
and edema caused by tumor
spread to lymphatic channels of
skin of breast
usually without an underlying
palpable mass
Is a clinical diagnosis verified by
biopsy of the tumor and
overlying skin.
Key words: lymphatic
involvement of skin, peau
d'orange, orange-peel skin, en
cuirasse
19. Paget’s disease
Crusty tumor of nipple
and areola, which may
be associated with
underlying tumor of
the ducts.
20. DCIS
In Situ: Abnormal cells that have not escaped the
part of the body where they developed
For Breast – abnormal cells in the lining of a milk
duct that have not invaded surrounding breast
tissue
Appearance of being precancerous when viewed
under a microscope, but
No ability to spread as cancer cells would
After DCIS, increased risk of invasive breast
cancer from 2 to more than 8 times higher than
the risk found in general population
21. Grade (differentiation)
Assigned by pathologist
How close does the bx resemble normal
tissue
Helps predict prognosis
Lower number indicates slower-growing
cancer that is less likely to spread
Higher number indicates a faster-growing
cancer that is more likely to spread
22. Grades
Grade 1 (well differentiated) cancers have
relatively normal-looking cells that do not
appear to be growing rapidly and are
arranged in small tubules.
Grade 2 (moderately differentiated) cancers
have features between grades 1 and 3.
Grade 3 (poorly differentiated) cancers, the
highest grade, lack normal features and tend
to grow and spread more aggressively
26. Breast Cancer Staging (TNM)
Stage Tumor (T) Node (N) Metastasis (M)
Stage 0 Tis N0 M0
Stage 1 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 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1, N2 M0
Stage IIIB T4 any N M0
any T N3 M0
Stage IV any T any N M1
27. Treatment
Surgery
Mastectomy
Lumpectomy
Removal of axillary lymph nodes (for invasive cancers)
Sentinel node biopsy
Axillary dissection
Radiation
Usually after surgery
Chemotherapy
Combinations of drugs
Hormone therapy
Tamoxifen, others
28. Estrogen & Progesterone
Receptor Status
Proteins on the surface of cells that can attach to
substances such as hormones, that circulate in
the blood.
Normal breast cells & some breast cancer cells
have receptors that attach to estrogen and
progesterone.
Play a role in the growth and treatment of breast
cancer.
ER-positive tumors have a better prognosis and
are more likely to respond to hormone therapy
About 2/3 breast ca contain at least one of these
Higher percentage in older women
29. Premenopausal: Tamoxifen
Ovaries produce estrogen, sent through
bloodstream directly to the breast
Tamoxifen mimics estrogen
Attached to receptors, keeping real
hormones out
30. Postmenopausal: Aromatase
inhibitors
Produce most of their estrogen outside the
ovaries
Generated through androgen hormones store
in fatty tissue and adrenal glands
In a biochemical process started by the
enzyme aromatase, androgen is converted
into estrogen, into bloodstream and to breast
Aromatase inhibitors “block” the process
31. Aromatase Inhibitors (AIs)
Steroidal AIs
Aromasin (exemestane)
Nonsteroidal AIs
Arimidex (anastrazole)
Femara (letrozole)
Many clinical trials showing significant results in
both reduced breast cancer relapse, as well as
reduced rates of metastatic disease
Now being studied in various scenarios with
Tamoxifen
32. HER2/neu Status
human epidermal growth factor receptor 2
A protein involved in normal cell growth
Important in the control of abnormal or
defective cells that could become cancerous
HER2/neu positive cancers have an excessive
amount of the HER2/neu cancer gene protein
in and around their cells.
33. Herceptin
Considered a targeted therapy or an immune
treatment
Given IV, once every 2-3 weeks
Targets the HER2 protein production
Helps stop the growth of the HER2 positive
cancer cells
Helps prevent recurrence
34. Tests for HER2 Breast Cancer
IHC: ImmunoHistoChemistry – measures the
production of the protein by the tumor.
Ranked as 0, 1+, 2+ or 3+
3+ = HER2 positive cancer
FISH: Fluorescence In Situ Hybridization –
probes to look at the number of HER2 gene
copies in the tumor cell.
35. Treatment Options are
changing
Intraductal (in situ) – no longer recommend total
mastectomy (recent)
Treatment options may vary with age
Brachytherapy (mammosite)
Patients >45 or >50
Node negative
Small tumors
Combinations of tamoxifen/AIs
Avastin – new class of drug
Blocks formation of blood vessels that supply tumors