Management of Breast Cancer

By Hussein M. Khaled
Prof. Medical Oncology Vice President Post graduate Studies and Research Cairo University
1

BREAST CANCER Worldwide incidence in females*

Western Europe Eastern Europe Japan Australia/ New Zealand South Central Asia Northern Africa Southern Africa Central America

67.4 36.0 28.6 71.7 21.2 25.0 31.5 25.5 86.3

North America
*Incidence per 100,000 population.

Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.

CANCER CONTROL
EARLY DETECTION PRIMARY PREVENTION DIAGNOSIS

TREATMENT

BREAST CANCER
Signs and symptoms at presentation

Mass or pain in the axilla

Palpable mass Thickening Pain

Nipple discharge
Nipple retraction

Edema or erythema of the skin

4

BREAST CANCER Diagnosis path

Evaluation for biopsy
Cyst Normal

Palpable mass

Nonpalpable mass Cyst aspiration

Biopsy
Excisional biopsy Core-cutting needle biopsy Fine-needle aspiration

Needle localization

If persistent, short-term follow-up with surgeon

Insufficient evaluation, rebiopsy

Ductal carcinoma in situ

Invasive cancer

Lobular carcinoma in situ

Benign

Continued appropriate screening

Treatment Path

Staging Classification of Breast Tumour

Early Breast Cancer

10

11

NSABP B-06:
Effect of Lumpectomy v. Mastectomy on Survival
Cohort A
DISTANT DISEASE-FREE SURVIVAL (%)

Cohort B

Cohort C

YEAR
Total Mastectomy: Lumpectomy: Lumpectomy + XRT: 692/265 699/302 714/278 No. of patients / No. of recurrences 569/233 634/282 628/253 494/192 520/236 515/204

12

13

HT

14

15

16

HER2 testing algorithm

Patient tumour sample IHC 0 1+ FISH/CISH

2+ FISH/CISH

3+ Herceptin therapy

+ Herceptin therapy

+ Herceptin therapy
Adapted from Bilous M, et al. Mod Pathol 2003;16:17382 Hanna W. Breast 2005;14(Suppl.1)S17 (Abstract 10)
17

Locally Advanced Breast Cancer

18

19

20

21

22

23

24

25

What elements drive therapy decision making ?

Prognosis

Co morbidity

Treatment efficacy

Treatment toxicity
26

GUIDELINE RECOMMENDATION FOR CHEMOTHERAPY FOR STAGE I BREAST CANCER

T1a (0-5 mm) T1b (6-10 mm)

T1c (11-20 mm)

NCI NCCN*)

ER + ER -

St. Gallen

ER + ER -

Not Recommended

Optional

Recommended

*) NCCN = National Comprehensive Cancer Network

27

www/Adjuvant on line !

28

The Breast

Health Global Initiative (BHGI)

Guideline Publication 2003

CONSENSUS STATEMENTS

Early Detection Panel

Diagnosis Panel Treatment Panel
29

BHGI GLOBAL SUMMIT 2005:

Guideline Stratification

Breast J 2006;12 Suppl 1:S117-120

30

Diagnosis

Level of resources

Clinical

Pathology

Imaging and lab tests

History Physical examination Clinical breast examination Basic Surgical biopsy Fine-needle aspiration biopsy Cytology and/or pathology report describing tumor size, lymph node status, histologic type, tumor grade Diagnostic breast ultrasound +/diagnostic mammography Plain chest radiography Interpretation of biopsies

Core needle biopsy Limited Image guided sampling (ultrasounographic +/mammographic)

Determination and reporting of ER and PR status

Liver ultrasound Determination and reporting of margin status Blood chemistry profile / complete blood count (CBC) Diagnostic mammography

Enhanced

Preoperative needle localization under mammographic or ultrasound guidance

On-site cytopathologist Bone scan

Stereotactic biopsy Maximal Sentinel node biopsy

HER-2/neu status CT scanning, PET scan, MIBI scan, breast MRI

IHC staining of sentinel nodes for cytokeratin to detect micrometastases

31

Controversial Issues :

FNAC or Frozen Sections 5 or 10 years of HT T and AI Type of CT Herceptin and others Pre or post op CT Ov ablation Cases who do not need systemic treatment
32

Cancer Treatment
S

Chemo.

Radio.

Types of cancer treatment Application of cancer treatment

33

Cost of cancer treatment

Situation Analysis Egypt

34

EGYPT

Gharbia Populationbased registry

35

Incidence Rates of Common Sites of Cancer Population Data: Females

Rate per 100 000 pop.
60 50 40 30 20 10 0
Breast NHL Liver ColonRectum Ovary Bladder Brain&CNS Thyroid Lung

49.6

Crude Rate

ASIR

37.8

10.7 8.1 4.1

3.75.2

3.7 5

3.4

5.3

3 3.5

2.3 3

2.43.6

36

GLOBAL STATISTICS: Age-Specific Rates / 100,000 Females (all ages)

Globocan 2002 (IARC) 37

The National Cancer Institute Cairo University www.nci.cu.edu.eg

Cairo University

National Cancer Institute

38

NCI Most Common Sites in Males and females

39

National Cancer Registry

40

Age structure of

Female breast cancer patients.

<35 3540455055606570+

Proportion 7.7 12.6 14.8 17.6 16.2 10.4 11.2 5.0 4.5

Cumm. % 7.7 20.3 35.1 52.7 68.9 79.3 90.5 95.5 100.0

41

Age-specific Incidence Rates of Breast cancer in younger age groups: Egypt and US SEER

20-24 25-29 30-34 35-39 40-44 45-49 50-54

Egypt 1.4 9.8 28.9 63.6 96.7 171.5 181.2

US SEER 1.3 7.1 25.2 61.7 117.5 192.1 253.1

42

Projection of Magnitude of Breast Cancer in Egypt: 2025, 2050

Magnitude of Breast Cancer in Egypt: 2025

Population size: 51 million females Crude incidence rate: 55.1./100,000 females Incidence: 14,000 28,000 breast cancer cases Prevalence: 42,000 84,000 breast cancer cases

Magnitude of Breast Cancer in Egypt: 2050

Population size: 64 million females Crude incidence rate: 68.8./100,000 females Incidence: 14,000 44,000 breast cancer cases Prevalence: 42,000 132,000 breast cancer cases

43

Breast cancer T stage 1984 - 2006, Port Said, Egypt

80 70 60 50 40 30 20 10 0 84-1985 86-1988 94-1999 T1 T2 2004 T3 2005 T4 2006

44 SOURCE: Prof. Dr. Ahmed Elzawawy

Cancer Control in Egypt

45

Inflammatory Breast Cancer (IBC)

Swollen Erythema

Peau dOrange
Frequently Mistaken for Mastitis
46

ClinicoPathological Correlation in Breast Cancer Cases

(2002)

Revision of the slides of 212 patients. Only 16 patients had both clinical and pathological features of IBC (8%) Age distribution 4 patients 35 yrs or less 8 patients 45 yrs or less 8 patients More than 45 yrs The youngest 25 yrs The oldest 76 yrs
47

Biologic profile Immunphenotypic signature

More than 90% of IBC showed positive axillary nodes. IBCs are characterized by:

High histologic grade tumors with high Nuclear grade, necrosis and high PCNA and MIB1(Ki-67) labeling indices.
ER & PgR are frequently negative. p53 > 70% positivity. HER-2/Neu > 60%.
48

Tumor emboli and LYVE-1 and RhoC expression in IBC tumors from Egypt and the United States

49

RhoC Scoring and Tumor Emboli for Egyptian patients with IBC and non-IBC

IBC (N=46) No. (%) RhoC Score 1 2 3 4 RhoC Categories 1-2 3-4 Tumor Emboli Mean SD 0-1 2-8 9+

Non-IBC (N=64) No. (%)

P-value

1 (2) 5 (10) 20 (44) 20 (44)

24 29 7 4

(38) (45) (10) (6)

<0.0001

6 (13) 40 (87)

53 (83) 11 (17)

<0.0001

14.1 14.0 1 (2) 19 (41) 26 (57)

7.0 12.9 32 (50) 18 (28) 14 (22

<0.0001

<0.0001

50

51

52

Thank you

Cairo University

National Cancer Institute

53