Breast CancerAdapted From: SEER’s Training Web Sitehttp://training.seer.cancer.gov.index.htmlMCR StaffSupported by a Cooperative Agreement between DHSS and the Centers for Disease Control and Prevention (CDC) and a Surveillance Contract between DHSS and MU

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.

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).

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

Five-Year Survival Rates(ACS Relative)

Stage 0 100%

Stage I 100%

Stage IIA 92%

Stage IIB 81%

Stage IIA 67%

Stage IIIB 54%

Stage IV 20%

http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_breast_cancer_staged_5.asp

9/13/2007

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

Reducing Risk Having children at early age Breast feeding Healthy body weight Exercise Anti-estrogens

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

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

Breast Anatomy

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

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.

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

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

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.

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)

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

Image source: National Cancer Institute

Paget’s disease Crusty tumor of nipple

and areola, which may be associated with underlying tumor of the ducts.

www.sunmed.org/cbesk2.jpg

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

Behavior Invasive (infiltrating)

In situ (15-20% of all breast cancers)

Synonyms for carcinoma in situ: noninfiltrating, intraductal, lobular carcinoma in situ, Stage 0, TIS noninvasive, no stromal involvement, papillary intraductal, papillary non infiltrating, intracystic, lobular neoplasia, lobular noninfiltrating, confined to epithelium,

intraepithelial, intraepidermal, DCIS, LCIS

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

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

Grade: Bloom-Richardson Bloom-Richardson (BR) Score

Frequency of cell mitosis Tubule formation Nuclear pleomorphism

Bloom-Richardson Grade Low grade = BR score 3–5 = grade 1 Intermediate grade = BR score 6, 7 = grade 2 High grade = BR score 8, 9 = grade 3

Diagnosing Breast Cancer Mammogram MRI Ultrasound Biopsy

Fine Needle Aspiration Core Needle Biopsy (stereotactic and other) Excisional biopsy (sometimes with wire localization)

Lymph node dissection and Sentinel lymph node biopsy

Sentinel Lymph Node Biopsy

A.D.A.M. illustration used with licensed permission.

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

Source: American Joint Commission on Cancer and International Union Against Cancer

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

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

Premenopausal: Tamoxifen Ovaries produce estrogen, sent through

bloodstream directly to the breast Tamoxifen mimics estrogen Attached to receptors, keeping real hormones

out

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

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

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.

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 http://www.cancer.gov/cancertopics/factsheet/therapy/herceptin

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.

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

Missouri Cancer Registry

Help Line: 800-392-2829 Help interpreting path report for staging

http://mcr.umh.edu

For further information, please contact: Sue Vest, Project Manager vests@health.missouri.edu Nancy Cole, Assistant Project Manager

colen@health.missouri.edu