Transcript Document

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.
•1990s 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
2nd leading cause of death

2nd most common cancer
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Incidence increases with
age
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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 5year survival rate is about 97%.
•Having regular screening is the key to early
detection.
Warning Signs
Warning signs and symptoms:
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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
 Annual mammograms,
starting at age 40
 Clinical breast exams
– every year starting at age 40
– every 3 years for women age
20-39
 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
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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 ,1st child at 17 yo, HRT
stopped 3-4 weeks when she felt the pain
Medication
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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 AfricanAmerican ,awake ,alert,no acute distress.
Vital Signs
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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 5x5 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 8x9 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 111A 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?
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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
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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 and 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