BREAST CANCER 101

A REVIEW OF PROBLEMS,
DIAGNOSTICS, AND
CLINICAL MANAGEMENT

Sabha Ganai, MD, PhD

Assistant Professor of Surgery
Southern Illinois University School of Medicine
My conflicts of interest are relevant to being a practicing
surgical oncologist.

DISCLOSURES
 Objectives
Provide an overview of trends in breast
cancer incidence and mortality
Review screening and diagnostic
modalities important for management of
breast cancer
Discuss therapeutic approches for breast
cancers
 Breast Cancer
1 in 8 (12.3%) lifetime risk for US women
Increased from 1 in 11 in the 1970s.

CA Clin J 2014; 64: 52-62.

CA Clin J 2014; 64: 9-29.
CA Clin J 2014; 64: 9-29.
CA Clin J 2014; 64: 9-29.
 Breast Cancer Incidence

CA Clin J 2014; 64: 9-29.

Breast Cancer Mortality
Breast Cancer Mortality

Breast Cancer Mortality has declined

by 34% since 1990.
 Incidence and Mortality

CA Clin J 2014; 64: 52-62.

 Incidence and Mortality

CA Clin J 2014; 64: 52-62.

 ACS Screening

CA Clin J 2014; 64: 52-62.

 The Controversy
What are the harms of mammography?
overdiagnosis?
more anxiety?
more biopsies?
time/days off work?
more cost?
 USPSTF (2009)
Biennial Mammography ages 50-74
The decision to start regular, biennial
screening mammography before the age
of 50 years should be an individual one
and take into account patient context,
including the patients values regarding
specific benefits and harms.
 Mortality Reduction
71% survival benefit
following ACS
screening guidelines
beyond 23% mortality
reduction achieved
following USPSTF
guidelines
Additional 5 lives
saved per 1000
women.
 Potential Harms
Call backs for additional imaging (anxiety)
False-positive biopsies
False-negative screen
Missed breast cancer (dense breasts)
Radiation-induced breast cancer risk
Over-diagnosis
detection of a cancer that might not otherwise
become clinically-apparent during screen
Potential Harms
 Screening women in 40s:
False-positive mammogram once every 10y
False-positive biopsy once every 149y
Invitation to treat women in 40s in Swedish
mammography studies led to 29%
reduction in breast cancer mortality over
16 years
 Annual vs. Biennual Screening
Annual screening leads to 30% lower recall
rates, detection of smaller tumors, and impact
on stage migration
Screening ages 40 to 79 is more cost-
effective than seat belts and airbags with
regard to cost-per-life-year gained
Better than drug development
 Adherence and compliance behaviors
If womens screening behaviors are
established earlier, adherence to screening
mammography improves over time.
Women respond to an endorsement of
guidelines.
Strategy to leave decision-making up in air
does not educate on risk stratification for
breast cancer
 Screening Breast MRI

CA Clin J 2007; 57: 75-89.

 Screening Breast MRI

CA Clin J 2007; 57: 75-89.

 Screening Breast MRI

Should be
limited to
centers
with biopsy
capabilities

CA Clin J 2007; 57: 75-89.

 Genetic Counseling Referral
Early-onset breast cancer (<50y)
Triple-negative breast cancer (<60y)
Two breast primaries or breast and
ovarian cancer
Two or more close blood relatives with
breast cancer
Male breast cancer
Pancreas cancer
Clustering of other cancers
 Genetic Testing
Hereditary Breast and Ovarian Cancer
Syndrome
BRCA1
60-80% lifetime risk breast cancer
20-40% lifetime risk ovarian cancer
BRCA2
40-60% lifetime risk breast cancer (5-10% male)
10-20% lifetime risk ovarian cancer
Pancreas and prostate cancer
 Genetic Testing
PTEN (Cowdens Disease)
25-50% lifetime risk breast cancer
Thyroid, endometrial, genitourinary cancers
p53 (Li-Fraumeni Syndrome)
>90% lifetime risk breast cancer
Sarcomas, brain tumors, adrenocortical tumors,
colorctal cancers
CDH1
40% lifetime risk breast cancer (lobular)
Hereditary diffuse gastric cancer
Molecular Subtyping
Breast Cancer Biology

ER Basal-like (Triple negative)

PR HER2
HER2 Luminal (ER+)
 Molecular Subtyping
Luminal (Hormone-Receptor+)
Responsive to tamoxifen and aromatase
inhibitors
HER2
Responsive to trastuzumab and newer
biologic therapies
Basal-like (Triple-negative)
 Triple Assessment
Clinical Exam
H&P
Imaging
Diagnostic mammography / ultrasound
Pathology
Core needle biopsy
 Biopsy
Stereotactic Core Needle Biopsy
Ultrasound-guided Core Needle Biopsy
If Cancer, should get ER/PR/HER2 IHC

Surgical (Excisional) Biopsy

Non-concordant results
Atypia on a core biopsy
Sampling error (10-20%)
Papillary lesions, radial scars
Surgical Management in 1900s
William Stewart Halsted
Halsted Mastectomy
Radical extirpation of
breast with pectoralis and
lymph nodes

Predicated on notion that

breast cancer spreads locally
and regionally via lymphatics
 Paradigm Shift
Bernard Fisher
1967 Chairman of
National Surgical Adjuvant
Breast and Bowel Project
(NSABP)
 Paradigm Shift
Bernard Fisher
because operable breast
cancer is a systemic
disease involving a complex
spectrum of host-tumor
interrelations, local-regional
therapy is unlikely to affect
survival.
Before 1971, if you had breast cancer,
chances are youd have to get your breast
cut off. Surgeons had been taught one thing:
radical surgery saves lives. It was Bernard
Fisher who changed their minds, getting
reluctant breast surgeons to enter their
cancer patients into clinical trials that tested
less aggressive surgery against the Halsted
radical mastectomy.
NSABP B-04
NSABP B-06
 Lowdown
Breast-conserving therapy (lumpectomy +
whole-breast radiation) and Mastectomy
have similar overall survival benefit
Includes Triple-negative cancers
Goal is clear-at-ink negative margins
2014 SSO/ASTRO guidelines
Mastectomy should be paired with referral
to a Plastics/Reconstructive Surgeon
 Oncoplastic Techniques
Mastectomy
Nipple-sparing and Areola-sparing
skin-sparing approaches
Partial Mastectomy
Various approaches accounting for location,
volume and aesthetic considerations
What about the Axilla?
Axillary Complications
 ACOSOG Z0011
Only applies to cT1-2N0 patients
undergoing breast conserving surgery with
radiotherapy
Observation is acceptable for SLN+ patients
If SLN+ after mastectomy, Axillary Lymph
Node Dissection is still recommended
 OncotypeDX
21-gene RT-PCR
recurrence score
Performed on
paraffin-embedded
specimens
Developed and validated on patient tumor
blocks from NSABP B-14 (TAM vs. Obs)
and B-20 (TAM vs. Chemo/TAM)
Hormonal Tx
Hormonal Tx
Hormonal Tx

Add Chemo
 The Future
Neoadjuvant Clinical Trials
Chemo before surgery
Assessment of response to therapy
Evolving role of surgical management of
axilla
Bigger surgery does not cure bad biology
Optimal screening paradigm in context of
better imaging strategies and therapies will
need to be determined
An individualized approach?
Questions?