breast cancer oncology john dewar. breast cancer commonest cancer in women 2 nd commonest cause of...
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BREAST CANCER Oncology
John Dewar
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Breast Cancer
Commonest cancer in women2nd commonest cause of death from cancer in womenSurvival improving – 5 yr. survival improved from 56% 1970 to 79% in 1999 (year of diagnosis)Increasing incidence – ageing population
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Presentation
Screening – age 50-64(70), small, impalpable
Symptomatic – lump in breast
8% with distant metastases
8% locally advanced/inoperable
84% operable
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TREATMENT
Surgery
Radiotherapy
Systemic therapy
hormonal therapy
cytotoxic chemotherapy
immunotherapy
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RADIOTHERAPY
Postoperatively to breast/chest wall nodal areas: axilla, supraclavicular
fossa, internal mammary nodesPrimary radical for locally advanced Palliatively to painful bony mets, skin deposits, brain mets etc.
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POSTOPERATIVE RADIOTHERAPY
Reduces the risk of local recurrence by about two thirds:
60% to 20%
30% to 10%
3% to 1%
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POSTOPERATIVE RADIOTHERAPY
All patients being treated conservatively (wide local excision/lumpectomy)
Mastectomy patients selectively – large tumour, extensive nodal involvement, involved margins etc.
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Postoperative Radiotherapy – acute side effects
Skin erythema to moist desquamation
Tiredness
Dysphagia if irradiating supraclavicular fossa
No alopecia
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Postoperative Radiotherapy – late effects
Local fibrosis and telangectasia
Lung fibrosis (rarely symptomatic)
Cardiac damage (ischaemic heart disease) – rarer now treatment better planned
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Postoperative Radiotherapy – late effects
Survival
Overall 5% improvement in breast cancer survival (at 15 yrs.) for 20% improvement in local control (4% improvement in overall survival)
Localised local recurrence can act as nidus for distant metastases
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SYSTEMIC THERAPY – adjuvant
Most operable, why not curable?
Occult distant metastases at presentation
Systemic therapy after surgery reduces the risk of recurrence and death – adjuvant therapy
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SYSTEMIC THERAPY – adjuvant
Hormone therapy: ovarian ablation, tamoxifen, aromatase inhibitors (ER/Pg +ve patients only)Cytotoxic chemotherapy: CMF, doxirubicin/epirubicin, taxanesTrastuzumab [Herceptin]
All decrease odds of death by about 17%, absolute benefit of about 6% at 10 years.
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SYSTEMIC THERAPY – adjuvant: side effects
Hormone therapy:
Infertility
Menopausal symptoms
Weight gain
Endometrial cancer
Deep venous thrombosis
Chemotherapy
Nausea & vomiting
Infertility
Alopecia
Neutropenia (sepsis)
Mouth ulcers
Lassitude
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METASTATIC DISEASE
Incurable but treatable
Optimise quality of life and survival
Median survival with mets: 2 years (20% at 5 yrs.)
Varies from acute aggressive disease to chronic disease (like diabetes, renal failure etc.)
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METASTATIC DISEASE
Assess extent of disease
Stage: local recurrence, lung, liver, bone
Hormone receptor status
HER2 receptor status
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METASTATIC DISEASELocal problems
Palliative radiotherapy: bony mets, brain mets etc.
Drainage of pleural or peritoneal effusions
Pining of pathological fractures
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METASTATIC DISEASE Systemic therapy
Hormone therapy if ER/Pg +ve
Chemotherapy
Bisphosphonates for bony mets
Trastuzumab if HER2 +ve
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METASTATIC DISEASE Systemic therapy
ER +ve: Hormonal agents: ovarian ablation, aromatase inhibitors, tamoxifen, progestagens in sequence
unless liver mets or lymphangitis carcinomatosa when usually chemotherapy
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METASTATIC DISEASE
Chemotherapy: CMF, anthracyclines, taxanes, capcitabine etc. etc.
Use in sequence so long as respond and patient fit
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BREAST CANCER
Need multidisciplinary management: nurses, surgeons, radiologists, pathologists, oncologists, GP. etc. etc.
Different patients have different needs
Most will need considerable support
Major impact on the patients but also their families