Primary Care Breast Cancer Part I: Screening

1
Primary CareBreast CancerPart I Screening

• Hilary Suzawa
• Med/Peds
• December 2006

2
Breast Cancer Incidence

• One in Eight (12) Lifetime risk of developing
  invasive breast CA
• Breast CA is the second most commonly dx CA among
  women (1stskin CA)
• 180,000 new cases annually
• Estimated 212,920 dx in 2006 per Up To Date
• Invasive breast CA accounts for 32 of new CA
  cases in American women
• Pre-invasive breast CA (DCIS) now accounts for
  25-30 of all newly dx breast CA detected by
  mammogram

3
Breast Cancer Mortality

• Second leading cause of cancer death in women
  (1stlung CA)
• 48,000 deaths per year
• Estimated 40,970 deaths in 2006 per Up To Date
• Invasive breast CA accounts for 15 of CA deaths
  in American women
• Main cause of death in women age 45-55 years
• Annual mortality rates from breast CA have
  decreased over the last decade

4
Risk Factors

• Most women with breast CA have no identifiable
  risk factors
• Female
• 1 of breast CA occur in men
• Incidence of breast CA increases with age

5
Risk Factors

• Race
• Overall White gt Black
• Women lt50 years Black gt White
• Black women more likely to die of breast CA than
  white women
• High social economic status

6
Risk Factors

• Personal history of breast CA
• Increases the risk of developing a new breast CA
  by 0.5-1 per year
• Early menarche and late menopauseincreased
  exposure to hormones
• Give birth to their first child after age 30 or
  who never become pregnant

7
Risk Factors

• OCP (?)
• OCP lt10 years has same risk as women who have
  never been on OCP
• FMH First degree relative, esp if dx
  pre-menopause
• 3-4 x increase risk
• Exposure to ionizing radiation
• Eg. Survivors of Hodgkins Disease

8
?????

• Chemical exposure
• Alcohol consumption
• Weight gain
• High-fat diet
• Induced abortion
• Physical activity

9
Risk Reduction

• Low fat, high fiber diet
• Reduced alcohol consumption
• Tamoxifen, Raloxifene

10
Genetics

• 8 of all cases of breast CA are hereditary
• 50 of these CA are related to BRCA-1 and BRCA-2
• Pre-menopausal women
• Bilateral breast cancer

11
Genetic Screening

• Insurance
• Job discrimination
• Prophylactic mastectomy and/or oophorectomy
• False-negative tests

12
Clinical Presentations

• Asymptomatic (screening only)
• Breast Mass
• Most common complaint
• 90 of all breast masses are benign
• Fibroadenoma, Cyst
• Breast Pain
• Mastalgia is rarely assoc with breast CA
• More common with fibrocystic change, HRT

13
Clinical Presentations

• Skin changes
• Erythema, edema, retraction of the skin or nipple
• Nipple discharge
• Discharge associated with Breast CA
• Discharge is spontaneous
• Assoc with a mass
• Localized to a single duct in one breast

14
Clinical Breast ExamRecommendations

• Part of Well Woman Exam
• ACS recommendations
• Pt age 20-39 years should have one every 3 years
• Pt age 40 years and older annually

15
Clinical Breast Exam Key Points

• Sitting and Supine positions
• Differences in size (asymmetry)
• Different arm positions
• Retraction of skin or nipple
• Prominent venous patterns
• Signs of inflammation or skin changes (peau
  dorange)
• Nipple discharge
• Axillary and supraclavicular LAD
• Teach self-breast exam

16
Suspicious Findings

• Mass
• Solitary
• Discrete
• Hard
• Fixed to skin or muscle (non-mobile)
• Unilateral
• Non-tender
• Area of skin thickening
• Breast CA is rarely bilateral when first
  dx/detected

17
Self Breast ExamsRecommendations

• ACS (American Cancer Society) recommends start at
  age 20 years
• Teach adolescents
• Monthly
• Same time each month, eg. Week after menses

18
Self Breast Exam Reminders
19
MammogramRecommendations

• American Cancer Society (ACS) and National Cancer
  Institute (NCI)
• For asymptomatic women
• Start age age 40 years
• Annually
• Screening women 50-75 years significantly
  decreases the death rate from breast CA
• Screening women gt75 years controversial but at
  any age screening detects breast CA at an earlier
  stage (risk-benefit analysis)

20
Mammogram
Bottom Line Uncomfortable but Necessary and
Important
21
Mammogram False

• Women age 40-69 years have a 30 chance of
  false-positive screening mammogram OR breast exam
  over a 10-year period
• False positive screening tests are higher for
  younger women because fewer of their breast
  masses are malignant (prevalence)

22
Mammogram False -

• 10-15 of all breast CA are NOT detected by
  mammogram
• A PALPABLE breast mass that is NOT seen on a
  mammogram should have a diagnostic work-up
• Breast ultrasound
• Needle biopsy
• Close follow-up

23
Screening Recommendations Review

• American Cancer Society
• Age 20-39 years
• Clinical breast exam every 3 years
• Monthly self breast exam
• Age 40 years and older
• Annual mammogram
• Annual clinical breast exam
• Monthly self breast exam

24
Screening Recommendations

• U.S. Preventive Services Task Force (USPSTF)
• Routine screening in women for breast CA every
  1-2 years
• Mammography alone OR mammography and annual
  clinical breast exam for women age 50-69 years

25
Early Screening

• Women with FMH of BRCA mutation should begin
  annual mammography between age 30-35 years
• H/o chest radiation (XRT)
• Mammograms may start as early as when patient age
  20s.
• eg. h/o Hodgkins Disease Childrens Oncology
  Group (COG) recommends start mammogram 8-10 years
  after chest XRT or at age 25 years (whichever
  later)

26
Other Imaging

• Ultrasound
• To differentiate b/t solid and cystic breast mass
• Helpful in younger pt with dense breast tissue
• Digital Mammogram
• Images may be enhanced by modifying brightness or
  contrast
• Initial studies show that digital mammograms are
  as accurate as standard radiographs
• Not FDA approved

27
Evaluation of Common Problems

• Cysts
• Solid Masses
• Nipple Discharge
• Breast Pain
• Pregnancy

28
Cysts

• Ultrasound
• Simple cyst
• Round or oval
• Sharp margins
• Lacks internal echoes
• Posterior acoustic enhancement
• Simple vs. Complex Cyst
• Aspiration of simple cyst
• Evaluate any masses that remain after cyst
  aspirated

29
Solid Masses

• Clinically suspicious mass should be followed
  even if normal mammogram
• Ultrasound
• FNA biopsy
• Lumpectomy with 1-cm margin
• Thickened area? monitoring

30
Nipple Discharge

• Suspicious for CA spontaneous, assoc mass,
  single duct, bloody
• Galactorrhea
• evaluate for prolactinoma
• Cytology of discharge rarely helpful
• Check mammogram
• Ductogram

31
Breast Pain

• Most commonly with fibrocystic change and
  uncommon with breast CA
• Breast Exam /- mammogram
• Tx for fibrocystic breast dz
• Pain meds
• Firm support bra
• Eliminate chocolate, caffeine
• Vitamin E supplements

32
Pregnancy

• Any mass in a pregnant or lactating woman should
  be thoroughly evaluated.
• 2 of breast CA are dx in pregnant women
• Ultrasound
• FNA biopsy and cytology

33
Susan G. Komen Foundation

• Website at www.komen.org
• Houston Affiliate
• 713-783-9188
• Race for the Cure
• Houston, TX
• Planned for Saturday 10/6/2007
• Any Med/Peds runners?

34
Gifts that Matter

• Consider purchasing holiday gifts that benefit
  Breast CA organizations
• Susan G. Komen
• Ford Warriors in Pink
• Pink Ribbon Store at www.TheBreastCancerSite.com
• Beauty Suppliers Sephora, Origins

35
Bibliography

• Apantaku L, Breast Cancer Diagnosis and
  Screening. American Family Physician 2000 62
  (3).
• Hurria A, Joyce R, Come S, Follow-up for breast
  cancer survivors Patterns of relapse and
  long-term complications of therapy, 3/10/06, Up
  To Date
• Hurria A, Joyce R, Come S, Follow-up for breast
  cancer survivors Recommendations for
  surveillance after therapy, 5/11/06, Up To Date
• Esserman L and Stomper P, Diagnostic evaluation
  and initial staging work-up of women with
  suspected breast cancer, 3/29/06, Up To Date
• Childrens Oncology Group Long-Term Follow-Up
  Guidelines at www.survivorshipguidelines.org

36
Primary CareBreast CancerPart II Diagnosis,
Treatment, Survivor Follow-up

• Hilary Suzawa
• Med/Peds
• February 2007

37
Overview

• Palpable Mass
• Imaging
• Mammogram
• Ultrasound
• MRI
• Breast Biopsy
• Prognosis
• Treatment Complications
• Breast CA Survivor Follow-up
• Recurrence vs. Second Primary

38
Breast Mass

• If the lesion is palpable and the estimated
  likelihood of malignancy is gt50, then effort
  should be made to have surgeon evaluate prior to
  any biopsy procedure
• Biopsy may lead to hematoma and inflammation
  (confounding)

39
Mammogram

• Breast Exam alone NOT sufficient for breast CA
  diagnosis
• Breast Cancer Detection Demonstration Project
  (BCDDP)
• lt10 of breast CA were detected solely by
  physical exam
• gt90 were identified by mammogram

40
Mammogram
Bottom Line Uncomfortable but Necessary and
Important
41
MammogramScreening vs. Diagnostic

• For women with sx or signs of breast CA,
  diagnostic mammogram is associated with higher
  sensitivity but lower specificity than screening
  mammogram
• Note
• Sensitivity (Rule OutSnout)
• Specificity (Rule InSpin)

42
MammogramViews and ACR Bi-RADS

• Mammogram views
• Spot compression
• Magnification views
• Varied angled views
• ACR BI-RADS scale American College of Radiology
  Breast Imaging Reporting and Data System

43
MammogramAbnormal Findings

• 2 general categories of mammogram findings
  suggestive of breast CA
• Soft tissue masses
• Clustered micro-calcifications
• Most specific mammographic feature of malignancy
  is spiculated soft tissue mass
• Nearly 90 of these lesions represent invasive CA

44
MammogramMicro-calcifications

• Micro-calcifications are seen in 60 of CA
  detected by mammogram
• Micro-calcifications are thought to represent
  intra-ductal calcification in areas of necrotic
  tumor
• Mammogram appearance alone can NOT differentiate
  between purely intra-ductal and invasive ductal
  breast CA
• ie, there is NO mammogram feature of basement
  membrane invasion

45
MammogramStaging

• Multi-focalseveral areas within one breast
  quadrant
• Signifies disease along an entire duct
• Multi-centricmultiple areas within different
  breast quadrants
• Signifies involvement of multiple ducts
• Intra-mammary LN mets
• Worse prognosis

46
Breast Ultrasound

• Adjunct to mammogram
• To differentiate between solid and cystic masses
• Negative predictive value in a patient with
  palpable breast mass and a non-suspicious
  mammogram is high (gt99)
• Simple cysts need no further intervention because
  risk of CA is very low

47
Breast MRI

• Nearly all breast invasive CA enhance on
  gadolinium contrast-enhanced MRI
• Possible uses
• Clinical staging
• Screening of contra-lateral breast
• Evolving role

48
Breast Biopsy

• If pt has suspicious mammogram OR palpable mass,
  then biopsy
• Percutaneous FNA
• Percutaneous core needle biopsy
• Vacuum-assisted biopsy
• Wire localization and excision

49
Breast Biopsy

• Fine-needle aspiration (FNA)
• 20-gauge needle for sample from solid mass for
  cytology
• Ultrasound or stereo-tactic guidance to assist in
  collecting FNA from a non-palpable mass
• Core Biopsy
• 14-gauge needle to remove cores of tissue from a
  mass
• Ultrasound or stereo-tactic guidance
• Small skin incision and local anesthesia

50
Breast Biopsy

• Excisional Biopsy
• May be the initial procedure of choice if high
  probability of malignancy
• Wire localization of the mass if not palpable
• Local anesthesia
• May be done as outpatient

51
Breast BiopsySLN biopsy

• Impact of breast biopsy on later Sentinel Lymph
  Node (SLN) biopsy
• Evaluation of SLN thought to be most successful
  in pt without prior breast surgery
• Esp for tumors of upper outer quadrant
• But at least one report suggests that pt who
  undergo pre-op breast biopsy do NOT have a higher
  rate of SLN compared to those who do not have
  pre-op breast biopsy

52
Breast BiopsyWhole specimen mammography

• Obligatory for clinically occult (non-palpable)
  lesions excised under mammogram localization
• Recommended for palpable lesions assoc with
  micro-calcifications
• Correlate with mammogram and check margins

53
Prognosis

• Most important prognostic marker is the number of
  positive lymph nodes
• Metastatic disease
• Most common sites bone, liver, lung
• Metastatic work-up and pre-treatment evaluation
• Physical exam
• Bilateral mammogram
• Labs CBC, Liver profile
• CT chest if planning XRT
• Bone scan if symptomatic or if elevated alk phos
• PET scan--??evolving
• Tumor markers (CA-15-3, CEA)NOT indicated
• Bone marrow biopsy--??not widely adopted
• Cardiac evaluation if plan anthracycline
  chemotherapy

54
Treatment

• Early stage (I, II) breast CA can be treated by
  either
• Mastectomy OR
• Breast Conservation Therapy (BCT) Excision of
  tumor mass XRT to residual ipsi-lateral breast
• Equivalent cancer-specific survival
• However, tx modality chosen does have
  implications for pattern of recurrence and
  long-term follow-up

55
Complications of TherapySurgery

• Infection Breast Cellulitis
• Seromaside effect of mastectomy
• Phantom Breast Syndrome
• Post-mastectomy pain syndrome
• Arm morbidity Ipsilateral arm lymphedema
• Avoid BP monitoring
• Avoid blood draws, vaccines, IV lines
• Meticulous skin and nail care (infxn risk)

56
Complications of TherapyXRT

• Brachial plexopathyweakness
• Rib fractures
• Soft tissue necrosis requiring surgical resection
• Radiation pneumonitiscough, SOB
• Second cancers
• Contra-lateral breast CA
• Soft tissue sarcomas
• Acute non-lymphocytic leukemia (AML)
• Lung CA
• Esophageal CA

57
Complications of TherapyChemotherapy

• Depends on chemotherapy regimen
• Premature ovarian failure
• Cardiac dysfunction
• Second cancers
• Possible cognitive dysfunction

58
Breast Cancer Survivors
59
Breast CA Survivor

• Who should do the follow-up?
• PCP
• Oncology
• Surgery
• Radiotherapy
• Combination?
• At least two RCT suggest that generalist F/U may
  be a cost-effective alternative to specialist care

60
Guidelines

• ASCO Guidelines (American Society of Clinical
  Oncology)
• National Comprehensive Cancer Network (NCCN)
• Steering Committee on Clinical Practice
  Guidelines for the Care and Treatment of Breast
  Cancer of Health Canada
• National Health and Medical Research Council of
  Australia

61
Follow-up post-surgery

• For asymptomatic Breast CA survivors
• Breast exam Q 3-6 months x 5 years
• Annual mammogram
• More intensive follow-up and sub-specialty visits
  have NOT been shown to improve survival

62
Recurrence

• Majority of recurrences occur during the first
  decade (esp years 2-5)
• Emphasis on surveillance during the first five
  years
• For women with DCIS or LCIS, risk of systemic
  recurrence is very low
• Major risk is for CA in the preserved breast or
  contra-lateral breast
• For women with invasive breast CA, there is risk
  for both local and distant mets and also for
  second primary breast CA

63
Recurrence vs. Second cancer

• Distinguish between two concepts
• Recurrence of the initial CA
• Development of a new second primary cancer
  (second malignancy)

64
Recurrence

• Treatment modality affects recurrence risk
• Long-term recurrence rates
• BCT (with XRT)7-20
• Mastectomy4-14
• BCT (without XRT) has a much higher rate of local
  recurrence compared to BCT (with XRT)
• Timing of recurrence differs
• Most post-mastectomy local failures occur in
  first 3 years post-op
• Recurrence occurs later after BCT (5-20 years
  post-treatment)

65
Second malignancy

• Breast CA survivors are at higher risk for
  developing a second primary breast CA
• If pt has inherited pre-disposition, rate of
  contra-lateral second primary breast CA is 0.5-1
  per year
• Second primary breast CA may occur gt5 years after
  initial therapythus, must have long-term
  surveillance
• Some patients may consider prophylactic
  contra-lateral mastectomy

66
Main Points

• If palpable mass OR suspicious mammogram, then
  biopsy
• Most specific mammogram feature of CA is a
  spiculated soft tissue mass
• Breast US in a pt with palpable breast mass and
  non-suspicious mammogram has high (gt99) NPV
• Mastectomy and Breast Conservation Therapy
  (excision XRT) have equivalent survival but
  different recurrence patterns
• Breast CA patients need long-term follow-up care

67
Bibliography

• Apantaku L, Breast Cancer Diagnosis and
  Screening. American Family Physician 2000 62
  (3).
• Hurria A, Joyce R, Come S, Follow-up for breast
  cancer survivors Patterns of relapse and
  long-term complications of therapy, 3/10/06, Up
  To Date
• Hurria A, Joyce R, Come S, Follow-up for breast
  cancer survivors Recommendations for
  surveillance after therapy, 5/11/06, Up To Date
• Esserman L and Stomper P, Diagnostic evaluation
  and initial staging work-up of women with
  suspected breast cancer, 3/29/06, Up To Date
• Childrens Oncology Group Long-Term Follow-Up
  Guidelines at www.survivorshipguidelines.org