Breast Cancer Cancer cancer is not just one

Breast Cancer

Cancer: cancer is not just one disease but rather a group of diseases. • All forms of cancer cause cells in the body to change and grow out of control. • Most types of cancer cells form a lump or mass called a tumor. • The tumor can invade and destroy healthy tissue. Cells from the tumor can break away and travel to other parts of the body. There they can continue to grow. • This spreading process is called metastasis. When cancer spreads, it is still named after the part of the body where it started. • For example, if breast cancer spreads to the lungs, it is still breast cancer, not lung cancer.

What Is Cancer? Cancer is the name given to a large number of diseases.

Breast Structure

• Over 75% of women who are diagnosed with breast cancer are age 50 or older. • Men can get breast cancer, although this is very rare. For every man who is diagnosed, over 100 women are found to have breast cancer. • Most women—about 80%—who get breast cancer do not have a sister or mother who has breast cancer.

• Excluding skin cancer, breast cancer is the most common cancer in women. • 1990 s the breast cancer death rate declined by the largest amount in over 65 years. • Heart disease is the leading killer of women. • Approx 97% of women diagnosed with breast ca at an early stage survive 5 yrs or more. • There is no single cause of breast cancer. Research has shown that several different factors increase the risk of breast cancer. • Genetic and lifestyle differences increase the risk for some cancers.

Breast Cancer Facts n 2 nd leading cause of death n 2 nd most common cancer Incidence increases with age n n All women are at risk

Breast Cancer Risk Factors that cannot be changed Age Family/Personal History Race Treatment with DES GENDER - All women are at risk Reproductive History Menstrual History Radiation Genetic Factors

Let’s talk about the most common risk factors that cannot be changed. Besides being a woman, you are at risk • As you get older • If you or close blood relatives have had or have this disease. A woman with breast cancer has 3 to 4 times a greater chance of developing a new cancer. • Depending on your race: we talked before that white women are more frequently diagnosed with breast cancer than black women. But black women die more of this disease. Asian, Hispanic, and American Indian women are at lower risk.

• Treatment w/ DES (Diethylstilbestrol)- Between 1940 and 1960, some pregnant women were given DES to lower their chances of miscarriage. Recent studies show that these women have a 35% increased risk of getting breast cancer. • Radiation: women who have had chest radiation treatment have a greater risk of breast cancer. • Genetic factors: about 1 case of breast cancer in 10 is linked to changes/mutations in certain genes. • Menstrual history: women having her menstrual periods before 12 years of age or who went through menopause after age 50 have a slightly higher risk. • Reproductive history: women that have no children or who have their first child after 30 have a 40% higher risk.

Breast Cancer Risk Factors that can be controlled Obesity All women are at risk Exercise Breastfeeding Alcohol Hormone Replacement Therapy Not having children Birth Control Pills

Now let’s take a look at the risk factors that can be controlled: • Obesity: Being overweight increases the risk, especially after reaching menopause if that weight gain took place during adulthood. • Exercise: Exercise can lower breast cancer risk by about 60% in adults. More research is being done to confirm these findings. • Breastfeeding: Studies have shown that breastfeeding lowers breast cancer risk, especially is breastfeeding lasts 1½ to 2 years. One study found that having several children and breastfeeding could reduce the risk of breast cancer by half. This may be because breastfeeding lowers a woman’s total number of menstrual periods.

• Alcohol: Alcohol is clearly linked with an increased risk of breast cancer. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol. • HRT: It has become clear that long term use (several years) of combined HRT (estrogens together with progesterone) for the relief of menopause symptoms may slightly increase the risk of breast cancer as well as the risk of heart disease, blood clots, and strokes. The breast cancers are also found at a more advanced stage. As well, HRT seems to reduce the effectiveness of mammograms. • Birth control pills: studies have found that women now using birth control pills have a slightly increases risk of getting breast cancer. • Not having children before the age of 30 increases a woman’s risk by 40%.

A Good Breast Health Plan 1. Mammograms 2. Clinical Breast Examination (CBE) 3. Self Awareness (Monthly Self Exams) (BSE)

Mammography refers to x-ray of the breast. Mammography is used to detect and diagnose breast disease both in women who have breast symptoms (problems such as a lump, pain or nipple discharge) and women who are asymptomatic (no breast complaints). • Early diagnosis is the key to surviving breast cancer. Mammography can prevent thousands of breast cancer deaths each year. Regular screening mammograms are the best way to detect breast cancer early, when it is easiest to treat. • When having a mammogram, women should ask their doctor when they can expect to receive the results. Regulations facilities to send women their results within 30 days.

• Older women are at highest risk for breast cancer, yet they are the least likely to get mammograms. • The ACS can tell women where they can get a mammogram. Call 1 -800 -ACS-2345. • By law, all mammography facilities must be certified by the U. S. Food and Drug Administration. • They must meet standards for the equipment used, people who work there, and records that are kept. • Mammography can detect cancers several years before it can felt through a clinical exam. • Breast abnormalities are discovered in one of three ways: by a woman herself, by her HCP during a physical exam, or by a mammogram. Many breast cancers are found by the woman herself, but the smallest cancers are found by mammograms. • Low-cost and free mammograms are available to low-income women through their local or state health department. • Annual mammograms are covered by Medicare and Medicaid. • Most breast lumps are not cancer.

Clinical Breast Examination A clinical breast examination (CBE) is an examination of your breasts by a health professional, such as a physician, nurse practitioner, nurse, or physician assistant. For this examination, you undress from the waist up. The health professional will first inspect (look at) your breast for changes in size or shape. Then, using the pads of the fingers, the examiner will gently palpate (feel) your breasts. Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues. The area under both arms and above and below the collar bones will also be examined. During the CBE is a good time for the health professional to teach breast self-examination to the woman who does not already know how to examine her breasts. Ask your doctor or nurse to teach you and watch your technique.

Breast Self-Examination (BSE) • Performing monthly breast selfexaminations, beginning at age 20 • During the CBE is a good time for the health professional to teach breast selfexamination to the woman who does not already know how to examine her breasts. • Ask your doctor or nurse to teach you and watch your technique.

Mammography Average-size lump found by woman practicing occasional breast self-exam (BSE) Average-size lump found by woman practicing regular breast self-exam (BSE) Average-size lump found by first mammogram Average-size lump found by getting regular mammograms

• This is the most common method to detect breast cancer. • Breast cancer takes years to develop. • When breast cancer is detected early, the 5 year survival rate is about 97%. • Having regular screening is the key to early detection.

Warning Signs Warning signs and symptoms: • • • Painless lump or thickening Thickening or swelling that persist Nipple pain or retraction Breast skin irritation or dimpling Spontaneous discharge Early breast cancer may not have symptoms.

Women should seek immediate medical advice is they have any of these warning signs: • A mass/lump that is painless, hard, and has irregular edges is more likely to be cancerous, but some rare cancers are tender, soft, and rounded. • A change in the size or shape of the breast. • A change in the way the skin of the breast, areola, or nipple looks or feels (for example, scaly, warm, swollen, red) • Many of these breast symptoms are due to benign breast conditions but only a doctor can really give you a diagnosis

American Cancer Society Screening Recommendations n Annual mammograms, starting at age 40 n Clinical breast exams – every year starting at age 40 – every 3 years for women age 20 -39 n Self-breast exams monthly, starting at age 20

• Mammography can prevent thousands of deaths. • Older women are less likely to get mammograms, and are at highest risk of getting breast cancer. • The American Cancer Society can tell women where they can get a mammogram when called at 1 -800 -ACS-2345 • Low cost and free mammograms are available at all health departments- we will talk about this in a few moments • Annual mammograms are covered by Medicare and Medicaid

Breast Cancer Treatments • • • Surgery Chemotheraphy Radiation Therapy Hormone Theraphy Immunotherapy

Nutrition Guidelines • Eat a variety of healthful foods, with an emphasis on plant sources. • Adopt a physically active lifestyle. • Maintain a healthful weight throughout life. • If you drink alcoholic beverages, limit consumptions.

Case Study Chief Complaint I have pain in my breast and under my arm.

History of patient illness • Diana Jackson is 69 yo, black woman, whose history date back to 3 -4 weeks ago when she noticed a painful lump in the upper quadrant of her left breast , including the axillary area. • A mammogram was done that was suggestive of malignancy. • NOTE: she didnot have regular mammogram previously (here, we can realise the importance of routine mammogram in early detection of breast cancer)

Patient medical history • 1 -Angioplasty 5 years ago , pt denies any chest pain since. • 2 -HT, canot rememmber sice when. • 3 -Cholecystectomy. • 4 -Hysterectomy at age 45 • 5 -No family history of cancer

Social History • Quitted smoking 18 y ago • She denies any tobacco or drug use • Endocrine hx • Menopause at 45 , 1 st child at 17 yo, HRT stopped 3 -4 weeks when she felt the pain

Medication • • 1 -Adalat xl 90 mg od 2 -Zestril 20 mg od 3 -Paxil 30 mg od 4 -Tylenol 3 (2 tabs prn for back pain ) • Allergy : no known allergy • Gen. : Moderately obese 69 yo African. American , awake , alert, no acute distress.

Vital Signs • • BP =130/84 RR=88 P=77 T=37. 1 HT=165 cm WT=78 kg BSA= 28. 65

Breast : the right one appears normal The, left one , we noticed the following: • Skin retraction with arms elevated , no nipple retraction or discharge expressible, edema of skin in the left upper quadrant w/o associated erythema , hard 5 x 5 cm mass in the upper outer quadrant not fixed to skin , no ulceration, 2 cmfirm, tender palpable mass in axilla (lymph node enlargement) • Other organs are ok , no thing abnormal (lung , liver, abdomen , spines )

Mammogram : Advanced carcinoma associated diffused skin thickening and retraction -Lymphadenopathy with an enlarged lymph node approximately 2 cm in diameter suggested metastatic node -The size of malignant mass was 8 x 9 cm Ultrasound and Biopsy : -Solid mass favouring malignancy, abnormal lymph node apperance and evaluation suggested malignancy. CONCLUSION : Breast canrcinoma, ductal type

Questions • 1 -Identify drug therapy related problems? • Patient had angioplasty , so she has coronary problem (MI OR ANGINA ) so , she should be on an anti-thrombus medication which can be aspirin 80 mg od. • Patient is using tylenol 3 for back pain and she has risk of having constipation and straining and this is not good at all for people with coronary problems , better to use plain tylenol • Patient was on HRT although she has coronary problem (this is contra indication )

What is the patient stage of cancer? • According to National Cancer Institute , it is stage 111 A because the mass is larger than 5 cm and it is extended to the lymph node.

What is the goal of treatment of this patient? • The goal is to eradicate the tumour and prevent spreading of the disease to the adjacent organs or bones(chest wall).

What is the prognosis for this patient based on the tumor size and node status ? The disease is metastatic and liable to extend to the chest wall and lung as well as other organs if not treated aggressively.

List the general treatment options available for this patient ? • It may include the following : • Breast conservative surgery to remove only the tumor and some surrounding breast tissues , followed by lymph node dissection and radiation therapy. OR • Modified radical mastectomy with or w/o breast reconstraction surgery • THEN

Adjuvant Therapy • This is the treatment given after surgery to increase the chance of cure , and it may include : • 1 -Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy. • 2 -Systemic chemo therapy with or w/o hormonal therapy • 3 -Hormonal therapy. • 4 -TRUSTAZUMAB (Herceptin) inj. Combined with systemic chemo therapy.

Modified Radical Mastectomy • It is surgery done for patien with breast cancer in which the breast , most or all of the lymph nodes under the arm and the lining over the chest muscles are removed. some times the surgeon removes part of the chest wall muscles.

Breast Conservative Surgery • An operation to remove the breast cancer but not the breast it self. It may be: • Lumpectomy(removal of the lump). • Quadrantectomy(removal of quarter of the breast). • Segmental mastectomy(removal of the cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor).

Outline the optimum therapy plan for this patient? • • • 1 -Breast conservative surgery. 2 - Femara 2. 5 mg tablet od Side effects : hot flushes night sweats nausea vomiting muscle, joint, or bone pain excessive tiredness headache dizziness muscle weakness

If patient felt • • Chest pain Difficulty in breathing Contact the doctor immidiately Treatment is for 5 years with regular monitoring for any signs of metastasis of the tumor.

FEMARA • MAO • It is aromatase inhibitor • It act by inhibition of conversion of androgens which are the main source of estrogens after menopause

Iused • Hormonal therapy because the tumour is mainly due to long term use of HRT • In the case study they used chemotherapy and hormonal therapy (anastrozole – Arimidix ) but they didnot mension the chemotherapy regimen an dno surgery was done.

According to the case study • The patient came back after finishing the chemo. And starting on Arimidix , complaining from pain in her back and left • hip and CT scan for the abdomen , bone scanning , other additional lab tests , chest xray were done. • The conclusion was metastasis in bone and lung

New Plan • The physician decided to start chemo. On Xeloda (Capecitabine ) tab. • Stopping Arimidix is stated. • The patient did well with Xeloda , and after sex courses , the lung nodules were no longer detactable

BUT • The patient had PALMAR PLANTAR ERYTHRODYSESTHESIA and is unable to walk long distances due to pain in her feet , her hands were peeled and cracked • This is called hand foot syndromes and is a common and serious side effect of Xeloda tab. and should be treated and the medication my be resumed after symptoms

Continue • Subside but dose should be lowered • The physicain decided to stop and watching the patient off therapy. • 18 month later , the patient came with new pain in the right hip and left rib cage • Investigation was done and bone metastasis was revealed

Another new plan • The physician decided to start on • Faslodex inj. (Fluvestrant ) which is estrogen recetor antagonist.

Clinical Pearl • Breast cancer in early stage is a very highly curable cancer (stage 1 has 70% to 90% disease free survival ) but in advanced stages the spread of disease virtually eliminate the possibility of cure (in stage 4 , up to 10 % survival with minimal disease but are rarely cured ).

SO • This is very evidence supporting routine screening and patient education efforts,

THANK YOU • • • Moustafa Bekheet