Guidelines in management of breast cancer (UK experience)

1. Guidelines in management of breast cancer (UK experience) HAMDY ELMARAKBY MD FRCS

2. Breast Pain (cyclical or not) • No mass, mild pain: - <35 years: reassure and discharge. - > 35 years: mammography • No mass, moderate to severe pain: - < 35: ultrasound - > 35: mammography • Good support bra night and day, reduce caffeine intake, discontinue smoking, low fat diet, change the type of contraceptive pills and • Evening primrose capsules: - Gamolenic acid 240-300mg - 3-4 months at least - Danazol 100mg daily, assess after one month and continue for 6 months if response.

3. Cystic disease ( fibrocystic or not) • Palpable cysts, 7% of western women. • U/S, Mammography according to the age group. • Aspirate (free hand or ultrasound): - No blood, no residual lump, not re-accumulating: discharge - Rapidly recurrent, or blood: re-image, FNAC ?excision? • Multidisciplinary meeting (MDM).

4. Breast Cancer : Diagnosis • Monday am clinic (new patient): one stop (triple assessment). • Wednesday pm: multidisciplinary meeting (MDM). - Surgeons, Oncologist, Radiologist, Pathologist, breast care nurses, secretaries • Thursday am: New follow ups • Thursday pm: all other follow ups

5. Diagnosis • Breast lump, asymmetric thickening, nodularity, nipple discharge. • Triple assessment: clinical examination, radiological (ultrasound, mammography), Biopsy( wide bore needle, FNAC). • P value, U value, R value: 1-5(normal, benign, uncertain, suspicious, malignant). • Any P3,U3, R3 should be biopsied. • One stop clinic: patient will be given another appointment for the results if P3,U3,R3. • FNAC is only used with too small or inaccessible lesions and with nipple discharge. • All discordant results should be discussed in the MDM.

6. Ultrasound/Mammography • Ultrasound: breast abnormalities in ages <35 years, however, • It should not used in pain, and not as screening tool. • Mammography: - Breast abnormalities in ages >35 years. - National screening programme >50 years. - Early Screening (age < 50years,+family). - Nipple discharge. - Follow up in diagnosed breast cancer.

7. MRI • Ill defined tumours/ breast conservative surgery. • Multifocal disease? • Assessment of the integrity of breast prosthesis?. • Decision should be made at the MDM as mammography has taken over.

8. Excision biopsy • Diagnostic uncertainty on core biopsy or FNAC. • Lump >30mm in all age groups. • Discuss and consider excision of all lumps in > 35 years even if P2,R2. • MDM discretion

9. Breast Discharge • Single duct: • FNAC: performed by surgeons. - Benign (c2) or negative for blood: see 3 monthly for a year. - Uncertain (C3) or + ve for blood: consider surgery ( micro- dechoctomy <50 years, macro- dechoctomy>50 years). • MDM

10. Breast Discharge, continued • Multiduct: - Bilateral: benign (c2) or negative for blood, reassure and discharge. - Unilateral: same criteria /follow up 3 monthly for a year. - Uncertain (C3) or + ve for blood, or troublesome: consider mammmo dechoctomy after discussion in MDM. • Consider hyper prolactinaemia or drug induced galactorhea if profuse bilateral and embarrassing.

11. Other investigation tools • All patients should have FBC, LFT, CXR and bilateral mammogram. • No routine bone scan or liver US for operable breast cancer unless abnormal routine tests or if symptoms suggestive of metastasis.

12. Surgery • D.C.I.S. • Operable breast cancer. • Locally advanced disease.

13. Non surgical treatment • Adjuvant chemotherapy. • Adjuvant hormone treatment. • Adjuvant Radiotherapy. • Neo-adjuvant Chemotherapy.

14. Male breast cancer • <1% of breast cancer and < 1% of all male cancers. • Guidelines are essentially the same as female breast cancer. • Clinical outcome when matched for age, stage and treatment protocol are similar to females ( Perkins and Middleton BMJ 2003).

15. Surgery for early breast cancer • Non invasive breast cancer (DCIS): - No absolute consensus. - Lesions < 4cm: WLE with 1cm safety margin. No axillary surgery. - Lesions > 4cm or multifocal consider mastectomy. - Axillary node sampling if extensive multifocality (1-5% lymph node involvement) ( Dixon 1998) - DXT: beneficial - Hormonal treatment: less certain ( Lancet IBIS trial 2003). • Lobular carcinoma in situ (LCIS): a marker lesion for increased risk of invasive cancer/close surveillance.

16. WLE

17. WLE+ Augmentation Mammoplasty

18. Invasive Breast Cancer (Early) • Breast Conservative Tumour (BCT): solitary <3cm, or selected cases with > 3cm in large breast (MDM). • Contraindications: - multifocal, - recurrent disease after BCT, - patient choice, - tumour > 3cm, - centrally placed tumors, or - if DXT is contraindicated, - pregnancy, - age< 35 years( MDM).

19. Breast Conservative Surgery (BCS) • A cylinder of breast tissue from skin to deep fascia is removed. • No skin is removed unless superficial tumor. • Macroscopic radial margins should be at least 10-20mm and microscopic margins at least 5mm. • Radiopaque clips: 1( anterior surface),2(medial surface), 3(inferior surface). • Silk suture on tissues closest to nipple.

20. Breast conservative surgery

21. What’s next • Specimen x ray for all cases with a detectable mammographic abnormality. • If close margin: immediate re-excision at same operation. • 4 axillary node sampling if axillary clearance is not indicated. • ER and PR status in all patients. • Mark the cavity with 4 clips on the pectoral fascia for DXT( superior, inferior, medial and lateral).

22. Treatment of axilla • Incidence: 1%(DCIS),5%-28%(T1), 48%(T2), 68%(T3), 88%(T4). • Axillary sampling (4 node): - if clinically N0 • Axillary clearance: if N1 or +FNAC and if mastectomy is indicated for recurrent disease. • Not indicated if previously treated with radiotherapy.

23. Locally advanced Breast Cancer • large cancer(T3-4), skin or muscle or chest wall infiltration, matted L.N. • Full screen for metastasis( bone scan, liver US, possible CT chest). • MDM: select cases for adjuvant chemotherapy and hormonal ttt (Cancer;98:1150-60, 2003).

24. Locally advanced Breast Cancer • Hormonal: slowly growing, ER PR+, unfit patients for chemotherapy. • Chemotherapy: inflammatory carcinoma, ER, PR –ve, young patient <35. • Value: down staging, • Definitive surgery will entirely depend on the tumor response.

25. Chemotherapy • Adjuvant( in addition)/Neo-adjuvant (in advance/instead) of surgery. • Details pathology: tumour size, grade, nodal, receptor status, margins of excision and the presence or absence of vascular or lymph-vascular invasion. • Indications (risk factors): +ve nodes, grade 2-3, size>2cm,vascular invasion and receptor –ve tumors. • Anthracycline based e.g. 6 cycles of Epirubicin,5FU, Cyclophosphamide. Other combinations Epirubicin, Cyclophosphamide and Taxane.

26. Chemotherapy continued • HER2 receptor status is becoming increasingly important particularly in relapse patients who are candidates for Trastuzumab (Herceptin). • The benefits of chemotherapy in postmenopausal patients is increasingly appreciated making the traditional classification of patients into pre and post menopausal less crucial. • Chemotherapy is not routinely offered to patients>65years.

27. Hormonal therapy • All patients with estrogen/ progesterone receptors positive. • Tamoxifen 20mg/day for 5 years. • Exceptions: previous tamoxifen therapy or history of thrombo-embolism. • Should not simultaneously prescribed with DXT for fear of increased risk of pulmonary fibrosis. (Radiother Oncol 2002,Br J Cancer 2004). • Should not simultaneously prescribed with chemotherapy as it reduce its effect and significantly increase the incidence of thromboembolism. • ATTOM trial 5 more years of tamoxifen after finishing a 5 year treatment. Provided that the patients are disease free and had a complete resection of tumors.

28. Arimidex (Anastrozole) • A non steroidal aromatase inhibitor. • ATTAC trial suggests: it is stronger with better prognosis and lesser side effects than tamoxifen. • Nevertheless more arthralgia and fractures complication (Lancet 2005). • Receptor +ve postmenopausal.

29. Adjuvant Radiotherapy • Post BCS: DXT is given to the breast and the lower axilla in the tangential glancing fields. • DXT should be considered for all patients with completely excised DCIS who had undergone BCS. • Only those with lesions <10mm should be discussed at the MDM. • 4500-5000 cGY in 20-25 fractions daily. Options to give boost in younger patients. • DXT to supraclav. L.N: Should be considered with 4 or more pathologically involved axillary L.Ns, apical nodes involvement and with extra nodal spread of tumor.

30. Post-mastectomy Radiotherapy • Chest wall: - 4 or more pathologically involved axillary nodes, - primary tumor >5cm(large breast) - and tumor 3-5cm( small breast), - narrow deep margin <0.5cm, - evidence of lymph vascular invasion. • Irradiation to the axilla is only for those who have not had axillary clearance.

31. Follow up • Access to breast care nurse/unscheduled outpatient review and for post 5 years follow ups. • Patients are seen for 5years in the breasts cancer follow up clinic starting from 2 weeks postoperative where the results are conducted. • Alternating appointment every 3months between the oncologist and the surgeon for 2 years, then very 6 months for 3years. • Clinical examination to the breast and the lymph nodes.

32. Follow UP • Mammography is requested annually for 5 years. • After 5 years if < 50years, arrange biennial mammography until 50years. • if>50years then discharge to NHSBSP for 3yearly screening. • IF>70years self referral for 3yearly screening. • All patients diagnosed with distant metastasis should stop mammography surveillance. • Other investigations are only requested if symptoms develop e.g. back pain, lump, rash etc

33. Breast reconstruction • Patients should be aware prior to surgery for the possibility of breast reconstruction. • Primary? Delayed? • All patients should be offered the opportunity to meet another patient who underwent BR.

34. Breast Reconstruction

35. Breast reconstruction

36. Quality standards • All patients with suspected breast cancer should be seen by specialist within 2 weeks of GP referral. • More than 90% of GPs must receive feed back from the breast unit within one week of patients appointment. • One stop clinic: Clinical, imaging, biopsy should be performed at the initial visit.

37. Quality standards • >90% of patients should be diagnosed preoperatively. • <10% of patients should attend the hospital for more than one visit for diagnostic purposes. • >90% of diagnosed patients should be admitted for surgery within 2 weeks and 100% within 4 weeks. • BCS, BCN, MDM are compulsory.

38. Outcome of breast cancer • 60% of patients will develop some form of recurrence, 2/3(40%) will develop within 5 years. • 50% will eventually present with distant metastasis and die from the disease. • Nottingham prognostic index (NPI): Grade(1-3)+ N Stage (N 0-2)(1-3)+ (0.2xsize of tumor in cm)

39. Outcome of breast cancer • No (negative axilla), N1 (low axilla}, N2 (high axilla). • Good (score<3.4)(80% 10 year survival ),moderate (score 3.4-5.4)(40% 10 year survival) , poor (score >5.4) (15%10 year survival). • Example: 2cm,G2,N1= 0.4+2+2= 4.4 =moderate

40. Family history • Genetic predisposition in 5-10%. • However 15% of patients give family history. • Pedigree analysis questionnaire and qualitative risk assessment will be made. • Refer to regional genetic cancer clinic.

41. Family History • Risk factors: a close female relative had breast cancer <40, or had bilateral breast cancer or • 2 close female had breast cancer < 60 or one had breast and the other had ovarian cancer or both had ovarian cancer. • A male close relative had breast cancer at any age. • A close relative denotes a first and second degree. • Refer to regional cancer genetic clinic. • Moderate and high risk female will have an annual clinical assessment and mammography starting from the age of 35- 40 years. • At 50 years they are discharged back to the NHSBSP

42. Thank you