KANKER PAYUDARA

Epidemiologi
Penyebab dan Faktor Resiko
Gejala dan Tanda
Stadium
Tindak Lanjut
 Pendahuluan

• Profil Kesehatan Indonesia 2008 :

– Urutan pertama (2004-2007)
– 8277 kasus (16,85%)
– Insidens di Indonesia : 36,2 per 100.000
pr dengan angka kematian : 18,6 per
100.000 pr. (20.052 kasus). Data oleh
Global Burden of Cancer, 2008.
• RSCM :
– Penelitian terhadap 300 pasien  bedah,
(1989-1992) terbanyak : kanker payudara
lanjut lokal (66%).
– 1998-2002 : 27,5%, tetapi stadium IV
meningkat (47,4%).
– US : KPLL < 5%
 10 KANKER TERBANYAK DI INDONESIA
Number ICD Location Relative Frequency

1. 180 Cervix 18,41 %

2. 174 Women's breast 11,57 %
3. 173 Skin 8,24 %
4. 147 Nasopharynx 6,15 %
5. Unknown 5,16 %
6. 183 Ovaries 4,94 %
7. 196 Lymphoid nodes 4,91 %
8. 154 Rectum 4,42 %
9. 171 Soft tissue 3,50 %
10. 193 Thyroid 3,38 %

Source: Bulletin of Pathology Based Cancer Registry, BRK-IAP, No. 4, 1989.

 10 Kasus Kanker Terbesar (30 RS) di Jakarta
Tahun 2005-2007

Breast 18.38

Cervix Uteri 10.61

Bronchus and Lung 6.83

Colorectum 6.55
Topografi

Leukemia 5.82

Pharynx 5.71

Ovary 4.51

Lymph Nodes 3.60

Thyroid Gland 3.30

Hepar 2.74

0.00 5.00 10.00 15.00 20.00

Persen
 10 Kasus Kanker Terbesar (30 RS) Pada Laki-laki 10 Kasus Kanker Terbesar (30 RS) Pada Perempuan
di Jakarta Tahun 2005-2007 di Jakarta Tahun 2005-2007

Bronchus and Lung 13.68 Breast 28.88

Colorectum 10.50 Cervix Uteri 16.87

Pharynx 10.02 Ovary 7.13

Leukemia 8.39 Leukemia 4.30

Topografi

Topografi
Lymph Nodes 5.84 Colorectum 4.21

Prostate Gland 5.77 Thyroid Gland 4.05

Hepar 4.57 Pharynx 3.16

Renal Pelvis - Bladder 3.13 Bronchus and Lung 2.78

Soft Tissue 3.02 Corpus Uteri 2.53

Skin 2.62 Lymph Nodes 2.28

0.00 5.00 10.00 15.00 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00

Persen Persen
 PERBANDINGAN INSIDENS
KANKER DI INDONESIA

Padang Palembang Bandung Semarang Surabaya U. Pandang

1. Breast Cervix Cervix Cervix Cervix Breast

2. Soft tissue Skin Breast Breast Breast Skin
3. Unknown Breast Skin Skin Lymph nodes Cervix
4. Rectum Unknown Nasopharynx Unknown Skin Unknown
5. Ovary Nasopharynx Lymph nodes Ovary Nasopharynx Ovary
6. Cervix Placenta Unknown Nasopharynx Ovary Lymph nodes
7. Nasopharynx Rectum Rectum Lymph nodes Soft tissue Thyroid
8. Lymph nodes Oropharynx Ovary Rectum Thyroid Nasopharynx
9. Soft tissue Colon Soft tissue Thyroid Rectum Soft tissue
10.Prostate Lymph nodes Thyroid Soft tissue Colon Rectum

Ramli, JICC 1995

Anatomi

•Sappy’s plexus – lymphatics under areolar complex

•75% of lymphatics flow to axilla
 Payudara normal

Breast profile
A ducts
B lobules
C dilated section of duct to hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage

Enlargement
A normal duct cells
B basement membrane (duct wall)
C lumen (center of duct)

11
Illustration © Mary K. Bryson
 Ductal Carcinoma in situ (DCIS)

Ductal
cancer
cells

Normal
ductal
cell
12
Illustration © Mary K. Bryson
 Invasive Ductal Carcinoma (IDC – 80%
of breast cancer)

Changes in genome
of somatic cells

Ductal cancer
cells breaking
through the wall

The cancer has spread to

the surrounding tissues
Carcinoma refers to any
cancer that begins in the
skin or other tissues that
cover internal organs
13
Illustration © Mary K. Bryson
Illustration © Mary K. Bryson
BREAST CANCER
Incidence of major histologic types

Percent of all Infiltrating Carcinomas

78%

9%
4% 3% 5%
1%

Ductal Lobular Medullary Colloid Comedo Papillary

Adapted from McDivitt R et al, 1967.

 BREAST CANCER
Age-specific incidence (per 100,000)

Incidence rates

420
400 United
States

England
300
and Wales

Italy
200

France

100
Japan

0
20 25 30 35 40 45 50 55 60 65 70 75 80 85+
24 29 34 39 44 49 54 59 64 69 74 79 84 Age

Adapted from New Horizons in Cancer Management, SRI International, 1990.

BREAST CANCER
TNM stage grouping

Stage 0 Tis. N0 M0
Stage I T1 N0 M0
Stage IIA T0, T1 N1 M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0, T1, T2 N2 M0
T3 N1, N2 M0
Stage IIIB Any T N3 M0
T4 Any N M0
Stage IV Any T Any N M1
 BREAST CANCER
Survival by stage
Percent surviving
100
Stage 0

80 Stage I

Stage IIA
60

Stage IIB
40
Stage IIIA
20
Stage IIIB

0 Stage IV
1 2 3 4 5 6
Years after diagnosis
Pengaruh gen dan lingkungan
terhadap perkembangan kanker
(source: Pharmaceutical Research, September 2008)
BREAST CANCER
Risk factors

Female
History of breast cancer
Family history of breast cancer, especially in
first-degree relatives : 1,8 x
Benign breast “cancer”/ atypical hyperplasia : 5 x
Early menarche : 1,7-3,4 x, late menopause : 1,5 x
Late first pregnancy/no pregnancy : 1,5-4 x
Exogenous estrogens
Radiation
Diet, alcohol
Gejala dan tanda Kanker Payudara

Adanya BENJOLAN
Penebalan kulit
Nyeri

Benjolan di
ketiak

Cairan puting suiksu

Putting tertarik kedalam

Kulit merah atau luka

Lesung kulit
Penyebaran jauh(metastasis) kanker
payudara

Otak
Kelenjar getah
bening
Kulit Paru

Hati

Ginjal Tulang
Waktu terjadinya kanker
Detection
 American Cancer Society

• Skrining kanker payudara sedini

mungkin :
– Pr > 20 thn : sadari tiap bulan
– Pr > 20-40 thn : memeriksakan diri ke
dokter tiap 3 tahun
– Pr > 40 thn : memeriksakan diri ke dokter
tiap tahun
– Pr 35-40 thn : base line mammografi
– Pr > 50 thn : mammografi tiap tahun.
BREAST CANCER
Breast inspection

Skin dimpling
BREAST CANCER
Breast palpation
 BREAST CANCER
Regional nodes assessment
Waktu mamografi
Sebaiknya dikerjakan pada :
• Wanita usia diatas 35/40 tahun sebagai
baseline
• Wanita dengan faktor risiko tinggi
• 7-10 hari masa haid
 What Mammograms Show

Two of the most important mammographic

indicators of breat cancers
– Masses
– Microcalcifications: Tiny flecks of calcium – like
grains of salt – in the soft tissue of the breast
that can sometimes indicate an early cancer.

33
 Detection of Malignant Masses

Malignant masses have a more spiculated

appearance

benign

malignant

34
Mammogram – Difficult Case

• Heterogeneously dense breast

• Cancer can be difficult to
detect with this type of
breast tissue
• The fibroglandular tissue
(white areas) may hide the
tumor
• The breasts of younger
women contain more glands
and ligaments resulting in
dense breast tissue
35
Mammogram – Easier Case

• With age, breast tissue

becomes fattier and has
fewer glands
• Cancer is relatively easy
to detect in this type of
breast tissue

36
Biopsy
Penanganan Kanker Payudara

Surgery
Radiotherapy
Chemotherapy
Hormonal therapy
New therapies
Supportive care
 BREAST CANCER SCREENING PATH
Breast self-examination

Physical examination
(yearly)
– +

Screening mammogram
(guidelines)
Diagnostic imaging
- mammogram
- ultrasound
Normal Suspicious Equivocal - compression magnification film

Palpable
Equivocal or Probably
mass
suspicious benign
Cyst Normal
(not cyst)

Fine-needle aspiration Short-term

biopsy follow-up
Aspiration
 BREAST CANCER DIAGNOSIS PATH
Evaluation Normal
Cyst
for
biopsy

Palpable Nonpalpable
mass mass

Cyst
aspiration

Fine-needle aspiration Needle If persistent,

short-term
biopsy localization
follow-up
with surgeon

Insufficient Ductal Lobular Continued

Invasive
evaluation, carcinoma
cancer
carcinoma Benign appropriate
rebiopsy in situ in situ
screening

Treatment Path
BREAST CANCER
Therapeutic options

Surgery
Radiotherapy
Chemotherapy
Hormonal therapy
Immunotherapy
New therapies
Supportive care
 BREAST CANCER
Surgical options I

mass
mass

Local excision …... Quadrantectomy

Wide excision
 BREAST CANCER
Surgical options II

nodes

nodes

mass
mass

Modified radical mastectomy Radical mastectomy

Excised area Incision
Excised area
TERIMA KASIH
“HEALTH IS NOT
EVERYTHING, BUT ……………
WITHOUT HEALTH,……..
EVERYTHING IS NOTHING !”