Advanced breast cancer

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Dr. Junaid Ahmad

PGR Ward 4

Locally Advance Breast Locally Advance Breast CancerCancer

Locally Advance Breast CancerLocally Advance Breast Cancer

The CA which is large enough to not fit in stage 1 and 2 but not metastasized distantly (stage 4)

It is more than 5cm large T3&T4, and mainly stage 3

Unfortunately it is CA with which most of women of 3rd world countries presentLack of education (Breast self exam)Lack of Screening


On clinical presentation duties of a doctor is toDistinguish benign from malignantMake a definite diagnosis before treatment

Diagnosis is based onHistory and ExaminationUltrasound / X-raysBiopsy

○ Core Needle / Fine needle○ Excisional


TNM Classification definesT size of tumor

○ T1 = Less than 2cm greater diameter○ T2 = 2-5cm greater diameter○ T3 = Larger than 5cm greater diameter○ T4 = Invasion of Skin or Chest wall

T4a Chest wall fixationT4b Skin ulceration, Edema of skin or skin nodules

or thickening of skinT4c signs of both T4a and T4bT4d Inflamatory CA (red swollen warm

breast)


TNM Classification definesLymph nodes involvement

○ N0 = no lymph nodes involved○ N1 = 1-3 axillary lymph nodes○ N2 =

N2a = 4-9 axillary N2b = internal mammary lymph nodes

○ N3 = N3a = more than 10 axillaryN3b = both axillary and internal

mammaryN3c = supraclavicular lymph nodes


TNM Classification staging Stage IIA

○ T1 N1 M0○ T2 N0 M0

Stage IIB ○ T2 N1 M0○ T3 N0 M0

Stage IIIA○ T1 N2 M0○ T2 N2 M0○ T3 N1 M0○ T3 N2 M0

Stage IIIB ○ T4 N0 M0○ T4 N1 M0○ T4 N2 M0

Stage IIIC ○ Any T N3 M0


Appropriate treatmentsNeoadjuvant chemotherapySurgeryChemotherapyRadiation therapyBiological therapyOvarian ablationTamoxifen or aromatase inhibitors for

postmenopausal womenMonoclonal antibody therapy Supportive care


Neoadjuvant ChemotherapyThis is the chemotherapy which we advice

before the surgery

GoalsDecrease tumor sizeMinimize surgeryEstablish tumor sensitivity to chemotherapy


Surgery Role of surgery in Stage III breast cancer

involves a mastectomy and lymph node removal as a standard of care

There may be breast reconstruction surgery afterwards because with appropriate treatment 8 year survival rate is 40%


Chemotherapy for Breast CancerImproves disease-free and overall survivalDurations of more than six months do not

add major advantageAnthracycline-based combinations are better

than combination of cyclophosphamide, methotrexate, and fluorauracil (CMF)

Taxane-based combinations are more effective in the adjuvant setting

Trastuzumab in the adjuvant setting improves disease-free and overall survival


Radiation Therapy after MastectomyRadiation therapy should be part of the

treatment for stage III breast cancers and for disease that involves four or more lymph nodes

At a minimum, the chest wall and the supraclavicular fossa should be treated with doses of at least 50G


Biological Therapy It is a new approach. In about 25% of women

with breast cancer, an excess of a protein known as HER2 makes the cancer spread quickly. Herceptin is a new drug that's been approved to treat women with metastatic breast cancer that is HER2-positive. It stops this protein from making the cancer grow and makes chemotherapy more effective. It is most often used in combination with chemotherapy. Very recent studies have led to its use in early breast cancer.


Survival According to TreatmentSurgery only 36%Radiation only 29%Surgery plus radiation 33%Chemotherapy, surgery and radiation 63%

Health & Medicine

Advanced breast cancer