2. INTRODUCTION
OBreast cancer is cancer that
develops from breast tissue.
OBreast cancer ,the second leading
cause of cancer deaths in women,is
the disease women fear most.
OBreast cancer can also occur in
men, but it's far less common.
3. • In the last 30 years, doctors have made great
strides in early diagnosis and treatment of the
disease and in reducing breast cancer
deaths.
• 80% of breast cancers occur in women older
than age 50.
• In 1975, a diagnosis of breast cancer usually
meant radical mastectomy – (removal of the
entire breast along with underarm lymph
nodes and muscles underneath the breast. )
• Today, radical mastectomy is rarely
performed. Instead, there are more and better
treatment options, and many women are
candidates for breast-sparing operations.
4. ETIOLOGY
O The two variables most strongly associated
with the occurrence of breast cancer are
gender and age.
O Breast cancer is also caused by a genetic
abnormality (a “mistake” in the genetic
material). However, only 5-10% of cancers are
due to an abnormality inherited from your
mother or father. About 90% of breast cancers
are due to genetic abnormalities that happen
as a result of the aging process and the “wear
and tear” of life in general.
6. RISK FACTORS
O Gender: female (1% males)
O Race: more common in whites.
O Age: increases as a woman gets older.
O Relative : (mother or sister).
O Menstrual history :early on set late
menopause
O Childbirth: first child After the age of 30 or having
no children at all.
Pregnancy and breastfeeding are protective against breast
cancer
7. • Obesity
• Diet: Fat & Alcohol
• Lack of Physical Activity: Stress
• Radiation Exposure
• History of cancer: Breast, Uterus, Cervix, Ovary
• Hormones: Estrogens in Hormone replacement therapy &
Birth control pills
• Genetics:Certain conditions that are inheritated
70% have no risk factors
8. CLINICAL MANIFESTATION
General
■ The patient may not have any symptoms, as breast cancer
may be detected in asymptomatic patients though routine
screening mammography.
Local Signs and Symptoms
■ A painless, palpable lump is most common.
■ Less common: Pain; Nipple discharge, Retraction or
dimpling,
Skin edema, Redness or warmth.
■ Palpable local-regional lymph nodes may also be present.
Signs and Symptoms of Systemic Metastases
■ Depends on the site of metastases, but may include bone
pain,
difficulty breathing, abdominal pain or enlargement, jaundice,
mental status changes.
9. PATHOPHYSIOLOGY
O Breast cancer is a malignant tumor that starts in the cells of
the breast. Like other cancers, there are several factors that
can raise the risk of getting breast cancer. Damage to the
DNA and genetic mutations can lead to breast cancer have
been experimentally linked to estrogen exposure. Some
individuals inherit defects in the DNA and genes like the
BRCA1, BRCA2 and P53 among others. Those with a
family history of ovarian or breast cancer thus are at an
increased risk of breast cancer.
O The immune system normally seeks out cancer cells and
cells with damaged DNA and destroys them. Breast cancer
may be a result of failure of such an effective immune
defence and surveillance.
O These are several signalling systems of growth factors and
other mediators that interact between stromal cells and
epithelial cells. Disrupting these may lead to breast cancer
as well.
10. DIAGNOSIS
O Laboratory Tests
■ Tumor markers such as cancer antigen (CA 27.29) or
carcinoembryonic antigen (CEA) may be elevated.
■ Alkaline phosphatase or liver function tests may be
elevated in
metastatic disease.
O Other Diagnostic Tests
■ Mammogram (with or without ultrasound, breast MRI or
both).
■ Biopsy for pathology review and determination of tumor
estrogen/progesterone receptor (ER/PR) status and
HER2 status.
■ Systemic staging tests may include: chest x-ray, chest CT,
bone scan, abdominal CT or ultrasound or MRI.
Mammogram of normal
and cancer breast.
11. TREATMENT
The main types of treatment for breast
cancer are:
O Surgery.
O Radiation therapy.
O Chemotherapy.
O Hormone therapy.
O Targeted therapy.
O Bone-directed therapy.
12. SURGERY
O Surgery aims to remove the breast cancer
with a margin (border) of normal tissue to
reduce the risk of the cancer coming back
in the breast (known as local
recurrence) and to try to stop any spread
in the body. The amount of tissue
removed depends on the area of the
breast affected and the size of the
cancer in the breast.
13. TYPES OF SURGERY
1) Breast-conserving surgery
O This type of surgery is sometimes called partial
(or segmental) mastectomy. It is also
sometimes called lumpectomy or
quadrantectomy. In this surgery, only the part of
the breast containing the cancer is removed. The
goal is to remove the cancer as well as some
surrounding normal tissue.
O side effects: Include pain, temporary swelling,
tenderness, and hard scar tissue that forms in the
surgical site. As with all operations, bleeding and
infection at the surgery site are also possible.
14. 2) Mastectomy
Mastectomy is surgery to remove the entire breast.
All of the breast tissue is removed, sometimes along
with other nearby tissues.
a) Simple mastectomy: Also called total
mastectomy, the surgeon removes the entire
breast, including the nipple, but does not remove
underarm lymph nodes or muscle tissue from
beneath the breast.
b) Skin-sparing mastectomy: In this procedure,
most of the skin over the breast (other than the
nipple and areola) is left intact. This approach is
only used when immediate breast reconstruction is
planned.
c) Modified radical mastectomy: This procedure is
a simple mastectomy and removal of axillary
(underarm) lymph nodes.
15. Radical mastectomy: In this extensive operation,
the surgeon removes the entire breast, axillary lymph
nodes, and the pectoral (chest wall) muscles under
the breast.
side effects: wound infection, hematoma (buildup of
blood in the wound), and seroma (buildup of clear fluid in
the wound).
16. 3) Lymph node surgery
a) Axillary lymph node dissection (ALND): In this
procedure, anywhere from about 10 to 40 lymph
nodes are removed from the area under the arm
(axilla) and checked for cancer spread.
b) Sentinel lymph node biopsy (SLNB): Removes the
first lymph node(s) to which a tumor is likely to
spread (these are called the sentinel nodes).
Removing many lymph nodes increases the risk of
lymphedema , to lower this risk, doctors may use a
sentinel lymph node biopsy (SLNB).
side effects: As with any operation, pain, swelling,
bleeding, and infection are possible.
17. 4) Reconstructive surgery
• After having a mastectomy (or some breast-conserving
surgeries), a woman might want to consider having the
breast mound rebuilt; this is called breast reconstruction.
These procedures are done to restore the breast's
appearance after surgery.
Chronic pain after breast surgery
Some women have problems with nerve (neuropathic) pain
in the chest wall, armpit, and/or arm after surgery that
doesn’t go away over time. This is called post-
mastectomy pain syndrome (PMPS) because it was first
described in women who had mastectomies, but it can also
happen after breast-conserving therapy.
18. RADIATION THERAPY
O Radiation therapy (also called radiotherapy) uses
high-energy rays to kill cancer cells. It affects cells
only in the part of the body that is treated with the
radiation. Breast cancer radiation therapy may be
used to destroy any remaining mutated cells that
remain in the breast or armpit area after surgery.
O Radiation is also used to treat cancer that has
spread to other areas, for example to the bones or
brain.
O Radiation therapy can be given externally
(external beam radiation) or internally
(brachytherapy).
19. External beam radiation
O This is the most common type of radiation
therapy for women with breast cancer.
The radiation is focused from a
machine outside the body on the area
affected by the cancer.
O The extent of radiation depends on
whether mastectomy or breast-conserving
surgery (BCS) was done and whether or
not lymph nodes are involved.
O If mastectomy was done and no lymph
nodes had cancer, radiation is targeted at
the chest wall and the places where any
drains exited the body.
20. • If BCS was done, most often the entire breast
gets radiation, and an extra boost of radiation is
given to the area in the breast where the cancer
was removed to prevent it from coming back in
that area.
• If cancer was found in the lymph nodes under
the arm, radiation may be given to this area as
well. In some cases, the area treated may also
include supraclavicular lymph nodes (nodes
above the collarbone) and internal mammary
lymph nodes (nodes beneath the breast bone in
the center of the chest).
• Breast radiation is most commonly given 5 days
a week (Monday through Friday) for about 5
to 6 weeks.
21. Internal Radiation
O Sometimes called partial-breast
radiation or brachytherapy, for use after
lumpectomy. Internal radiation methods
typically use small pieces of radioactive
material, called seeds, which are placed in
the area around where the cancer was.
The seeds emit radiation into the
surrounding tissue. The area that's very
close to the site of the original cancer is
the area that is at highest risk of
recurrencence.
22. TYPES:
1)Interstitial brachytherapy: In this approach, several
small, hollow tubes called catheters are inserted into the
breast around the area where the cancer was removed
and are left in place for several days. Radioactive pellets
are inserted into the catheters for short periods of time
each day and then removed.
2)Intracavitary brachytherapy: This is the most common
type of brachytherapy. A device is put into the space left
from BCS and is left in place until treatment is complete.
There are several different devices that can be used:
MammoSite®, SAVI®, Axxent®, and Contura®.
Mammosite insertion Mammosite tube
23. SIDE EFFECTS
O Radiation therapy can have side effects,
and these vary from person to person.
O The most common side-effects are:
O Sunburn-type skin irritation of the targeted
area (which may range from mild to
intense)
O Red, dry, tender, or itchy skin
O Breast heaviness
O fatigue
24. CHEMOTHERAPY
O Chemotherapy is a treatment using anti-
cancer (also called cytotoxic) drugs
which aims to destroy cancer cells. It is
known as a systemic treatment.
O Many different types of chemotherapy
drugs are used to treat breast cancer.
They can be given in different ways and in
different combinations, according to an
individual’s situation.
25. Chemotherapy can be given in several ways. For breast cancer
the drugs are most commonly given:
• into a vein (intravenously)
• by mouth (orally) as a tablet or capsule.
1) Intravenous chemotherapy :The most
common way involves inserting a small needle and plastic tube
called a cannula into a vein, either in the back of the hand or lower
arm. The needle is removed and the plastic tube left in place. The
diluted drugs are then slowly injected into the vein. If a large
volume of fluid is used it can be given as an infusion (drip) through
the cannula over a fixed period of time.
• The cannula will usually be on the opposite arm to where you
had (or are having) surgery. This is to avoid the risk of
lymphoedema.
2) Oral chemotherapy: This is chemotherapy
taken by mouth and it may be given either as tablets or capsules.
26. 3) Electrochemotherapy : It is a new treatment
and is not widely available. It’s sometimes used to treat breast
cancer that has spread to the skin. Chemotherapy is injected
either directly into the area of skin affected or into the
bloodstream. An electric pulse is then used to help the
chemotherapy reach the cancer cells. Once inside the cancer
cells, the chemotherapy destroys them.
SIDE EFFECTS:
• risk of infection from not having enough white blood
cells, anaemia (a drop in the number of red blood cells)
and bruising and bleeding
• sickness (nausea) and vomiting
• hair loss or thinning
• sore mouth (mucositis)
• mouth ulcers
• fatigue.
27. Chemotherapy Regimens
• Doxorubicin 60 mg/m2 IV
• Cyclophosphamide 600 mg/m2
IV
• Fluorouracil 500 mg/m2 IV
• Epirubicin 100 mg/m2 IV bolus
• Methotrexate 40 mg/m2 IV,
• Paclitaxel 175 mg/m2 IV
28. Hormone therapy
O Hormone therapy is another form of
systemic therapy. It is most often used as
an adjuvant therapy to reduce the risk of
the cancer coming back after surgery, but
it can be used as neoadjuvant treatment,
as well. It is also used to treat cancer that
has come back after treatment or has
spread.
O A woman's ovaries are the main source of
the hormone estrogen until
menopause.
O Estrogen promotes the growth of cancers
that are hormone receptor-positive.
29. Hormonal therapy medicines treat hormone-
receptor-positive breast cancers in two ways:
• By lowering the amount of the hormone estrogen in the
body.
• By blocking the action of estrogen on breast cancer cells.
• Hormonal therapy medicines are NOT effective against
hormone-receptor-negative breast cancers.
Drugs that block estrogen
1) Tamoxifen: Tamoxifen blocks estrogen receptors in breast
cancer cells.it is called a selective estrogen receptor
modulator or SERM.
• This drug is taken by mouth, most often as a pill.
• The most common side effects of these drugs
include fatigue, hot flashes, vaginal dryness or discharge, and
mood swings.
30. 2) Toremifene (Fareston®): Toremifene is a drug similar to
tamoxifen. It is also a SERM and has similar side effects.
3) Fulvestrant (Faslodex®): Fulvestrant is a drug that first blocks
the estrogen receptor and then also eliminates it temporarily. It is
not a SERM – it acts like an anti-estrogen throughout the body.
Treatments to lower estrogen levels
1) Aromatase inhibitors (AIs): letrozole (Femara), anastrozole
(Arimidex), and exemestane (Aromasin). They work by
blocking an enzyme (aromatase) in fat tissue that is responsible
for making small amounts of estrogen in post-menopausal
women. They cannot stop the ovaries from making estrogen,
aIso are taken daily as pills.
2) Ovarian ablation: Removing or shutting down the ovaries
(ovarian oblation), the main source of estrogens, effectively
makes the woman post-menopausal.
• Permanent ovarian ablation can be done by surgically removing
the ovaries. This operation is called anoophorectomy,also done
with drugs called luteinizing hormone-releasing
hormone (LHRH) analogs, such as goserelin (Zoladex®) or
®
31. Less commonly used types of hormone therapy
• Megestrol acetate (Megace®) is a progesterone-like drug
used that can be used as a hormone treatment of advanced
breast cancer.
• Androgens (male hormones) may rarely be considered
after other hormone treatments for advanced breast cancer
have been tried. They are sometimes effective, but they can
cause masculine characteristics to develop such as an
increase in body hair and a deeper voice.
32. Targeted therapy
O Targeted cancer therapies are drugs or other
substances that block the growth and spread
of cancer by interfering with
specific molecules ("molecular targets") that
are involved in the growth, progression, and
spread of cancer. Targeted cancer therapies
are sometimes called "molecularly targeted
drugs," "molecularly targeted therapies,"
"precision medicines“.
O These therapies include hormone
therapies, signal transduction inhibitors, gene
expressionmodulator, apoptosis inducer, angi
ogenesis inhibitor, immunotherapies,
and toxin delivery molecules.
33. SIDE EFFECTS
The most common side effects seen with targeted therapies
are diarrhea and liver problems, such as hepatitis and elevated
liver enzymes. Other side effects seen with targeted therapies
include:
• Skin problems (acneiform rash, dry skin, nail changes, hair
depigmentation)
• Problems with blood clotting and wound healing
• High blood pressure
• Gastrointestinal perforation (a rare side effect of some
targeted therapies)
• SOME MONOCLONAL ANTIBODIES
• Trastuzumab (Herceptin)- man-made versions of a very
specific immune system protein. They are given into a vein
(IV).
• Pertuzumab (Perjeta®)- IV
• Ado-trastuzumab emtansine (Kadcyla™)-attached to a
chemotherapy drug. It is also given IV.
• Lapatinib (Tykerb)- Not an antibody. It is given as a pill.
34. Bone-directed therapy
O When cancer spreads to bones, it can cause pain
and lead to bones breaking (fractures) and other
problems. Drugs like Bisphosphonates and
Denosumab can lower the risk of these problems.
Bisphosphonates
O Bisphosphonates are drugs that can be used to
help strengthen bones and reduce the risk of
fractures and pain in bones that have been
weakened by metastatic breast cancer. Examples
include pamidronate (Aredia®) and zoledronic
acid (Zometa®). They are given intravenously
(IV).
O Bisphosphonates may also help against bone
thinning (osteoporosis) that can result from
treatment with aromatase inhibitors or from early
menopause as a side effect of chemotherapy.
35. SIDE EFFECTS
• Flu-like symptoms and bone pain
• Kidney problems, so people with poor kidney function
may not be able to be treated with these drugs.
• Osteonecrosis (damage) in the jaw bones or ONJ
Denosumab
• Denosumab (Xgeva®, Prolia®) is another drug that
can help reduce the risk of problems from breast
cancer metastasis to the bone. It works differently
from bisphosphonates.
• it seemed to help prevent problems like fractures
(breaks) better than zoledronic acid. It also can help
bones even after bisphosphonates stop working.
• drug is injected under the skin every 4 weeks.
36. SIDE EFFECTS
O low blood levels of calcium and phosphate
O ONJ
O does not seem to affect the kidneys, so it is
safe to take if patient have kidney problems.
Denosumab can also be used to strengthen
bones in breast cancer patients with weak
bones who are being treated with aromatase
inhibitors. When it is used for this purpose, it is
given less often (usually every 6 months).
