Breast cancer is an uncontrolled growth of breast cells that can occur in both women and men. Worldwide, it is the fifth most common cause of cancer death. Symptoms may include a breast lump, changes to the skin or nipple, or swollen lymph nodes. Diagnosis involves biopsy of suspicious breast tissue. Screening methods include monthly breast self-exams, annual clinical exams starting at age 20, and yearly mammograms starting at age 40. Risk factors include family history, age, genetics, lifestyle factors, and some medical conditions. Reducing risks involves healthy habits and screening.

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BREAST CANCERBREAST CANCER
BYBY
DR.T.FARIZAL FADIL Sp.BDR.T.FARIZAL FADIL Sp.B

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Breast cancer is an uncontrolled growth ofBreast cancer is an uncontrolled growth of
breast cells or breast tissue, which canbreast cells or breast tissue, which can
occur in both women and men. Worldwide,occur in both women and men. Worldwide,
breast cancerbreast cancer is the fifth most commonis the fifth most common
cause of cancer death (after lung cancer,cause of cancer death (after lung cancer,
stomach cancer, liver cancer, and colonstomach cancer, liver cancer, and colon
cancer)cancer)

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
Breast CancerBreast Cancer


Breast cancer is an uncontrolled growth of breast cells or breast tissue,Breast cancer is an uncontrolled growth of breast cells or breast tissue,
which can occur in both women and men. Worldwide,which can occur in both women and men. Worldwide, breast cancerbreast cancer is theis the
fifth most common cause of cancer death (after lung cancer, stomachfifth most common cause of cancer death (after lung cancer, stomach
cancer, liver cancer, and colon cancer).cancer, liver cancer, and colon cancer).
No one knows why some women get breast cancer, but Breast cancer theNo one knows why some women get breast cancer, but Breast cancer the
most common cause by :most common cause by :
 Age, the chance ofAge, the chance of getting breast cancergetting breast cancer rises as a woman gets olderrises as a woman gets older
 Genes, there are two genes, BRCA1 and BRCA2, that greatly increase theGenes, there are two genes, BRCA1 and BRCA2, that greatly increase the
risk. Having one close relative (mother or sister) with breast cancer doublesrisk. Having one close relative (mother or sister) with breast cancer doubles
your risk of getting breast canceryour risk of getting breast cancer
 Certain Medications, Taking hormone replacement therapy (HRT) drugsCertain Medications, Taking hormone replacement therapy (HRT) drugs
after menopause may increase your chance of getting breast cancer.after menopause may increase your chance of getting breast cancer.
 Personal factors, beginning periods before age 12 or going throughPersonal factors, beginning periods before age 12 or going through
menopause after agemenopause after age

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 Symptoms & DiagnosisSymptoms & Diagnosis ::
If you discover a persistent lump in your breastIf you discover a persistent lump in your breast
or any changes in breast tissue, it is veryor any changes in breast tissue, it is very
important that you see a physician immediately.important that you see a physician immediately.
Other thing that you should See your healthOther thing that you should See your health
professional if :professional if :
- A new lump in the breast- A new lump in the breast
- A lump that has changed- A lump that has changed
- change in the size or shape of the breast- change in the size or shape of the breast
- Pain in the breast or nipple that does not go- Pain in the breast or nipple that does not go
awayaway
- Skin anywhere on the breast that is flaky, red,- Skin anywhere on the breast that is flaky, red,
or swollenor swollen
- A nipple that is very tender or that suddenly- A nipple that is very tender or that suddenly
turns inwardturns inward
- Fluid coming from the nipple when not nursing- Fluid coming from the nipple when not nursing
a babya baby

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 The most important method used toThe most important method used to
diagnose breast cancer is by taking adiagnose breast cancer is by taking a
biopsy (abiopsy (a tissue sampletissue sample), The shape and), The shape and
appearance of the cells in the tissueappearance of the cells in the tissue
sample reveals whether the lump issample reveals whether the lump is
benign, which is true of the vast majority,benign, which is true of the vast majority,
or if it is cancerous.or if it is cancerous.

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 Type of Breast Cancer :Type of Breast Cancer :
 Ductal carcinoma in situ, is an early breast cancer in theDuctal carcinoma in situ, is an early breast cancer in the
milk ducts. It can be detected by mammograms and ismilk ducts. It can be detected by mammograms and is
normally easy to cure.normally easy to cure.
 Lobular carcinoma in situ, this is not considered to beLobular carcinoma in situ, this is not considered to be
breast cancer but a pre-cancerous condition. They justbreast cancer but a pre-cancerous condition. They just
have an increasedhave an increased risk of breast cancerrisk of breast cancer, so they are, so they are
given frequent checkups.given frequent checkups.
 Invasive lobular carcinoma, is a breast cancer that startsInvasive lobular carcinoma, is a breast cancer that starts
in the lobules and has spread. It's may difficult toin the lobules and has spread. It's may difficult to
diagnose because they do not always form a lump ordiagnose because they do not always form a lump or
show up on mammograms.show up on mammograms.

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 Types of Breast CancerTypes of Breast Cancer
 Ductal carcinomaDuctal carcinoma is the most common form of breast cancer.is the most common form of breast cancer.
Tumors form in the cells of the milk ducts, which convey milk to theTumors form in the cells of the milk ducts, which convey milk to the
nipples. Ductal carcinoma can either be invasive, with the potentialnipples. Ductal carcinoma can either be invasive, with the potential
to spread, or non-invasive.to spread, or non-invasive.
 Lobular carcinomaLobular carcinoma occurs in the lobules, which are the milk-occurs in the lobules, which are the milk-
producing glands. Lobular carcinoma can be invasive, with aproducing glands. Lobular carcinoma can be invasive, with a
tendency to spread, or non-invasive.tendency to spread, or non-invasive.
 Inflammatory breast cancer (IBC)Inflammatory breast cancer (IBC) is a rare, aggressive form ofis a rare, aggressive form of
breast cancer that affects the dermal lymphatic system. Rather thanbreast cancer that affects the dermal lymphatic system. Rather than
forming a lump, IBC tumors grow in flat sheets that cannot be felt informing a lump, IBC tumors grow in flat sheets that cannot be felt in
a breast exam.a breast exam. Read more about IBCRead more about IBC
 Recurrent breast cancerRecurrent breast cancer means that the cancer has returnedmeans that the cancer has returned
after being undetected for a time. Recurrent cancer can occur in theafter being undetected for a time. Recurrent cancer can occur in the
remaining breast tissue, and also at other sites such as the lungs,remaining breast tissue, and also at other sites such as the lungs,
liver, bones or brain. Even though these tumors are in a newliver, bones or brain. Even though these tumors are in a new
location, they are still called breast cancer.location, they are still called breast cancer.

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 Symptoms include:Symptoms include:
 Lump or mass in your breastLump or mass in your breast
 Enlarged lymph nodes in the armpitEnlarged lymph nodes in the armpit
 Changes in breast size, shape, skin texture or colorChanges in breast size, shape, skin texture or color
 Skin rednessSkin redness
 Dimpling or puckeringDimpling or puckering
 Nipple changes or dischargeNipple changes or discharge
 ScalinessScaliness
 Nipple pulling to one side or a change in directionNipple pulling to one side or a change in direction
 Many breast changes – including lumps – are not cancer,Many breast changes – including lumps – are not cancer,
but if you notice one or more of these symptoms forbut if you notice one or more of these symptoms for
more than two weeks, see your doctor.more than two weeks, see your doctor.

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 Symptoms includeSymptoms include
 •• lump or mass in your breastlump or mass in your breast
 •• enlarged lymph nodes in the armpitenlarged lymph nodes in the armpit
 •• changes in breast size, shape, skinchanges in breast size, shape, skin
texture or colortexture or color
 •• skin rednessskin redness
 •• dimpling or puckeringdimpling or puckering
 •• nipple changes or dischargenipple changes or discharge
 •• scalinessscaliness
 •• nipple pulling to one side or a change innipple pulling to one side or a change in
directiondirection

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• age Most cases occur in women 50 or older; it is less
• common in women 35 or younger. Age is the most
• influential risk factor.
• • family history Your risk is higher with a family history
• (especially mother, sister, daughter) of breast and/or
• ovarian cancer.
• • hormones / childbirth Your risk is higher if you had
• your first period before age 12, began menopause after
• age 55, never had children or had your first child after
• age 30. Postmenopausal use of hormonal therapy
• increases your risk of developing breast cancer.
• • previous biopsy If you’ve had abnormal breast biopsy
• results or benign breast diseases requiring biopsies, you
• may be at increased risk. Other breast diseases such as
• atypical hyperplasia, lobular or ductal carcinoma in situ
• are risk factors, too.
• • education / socioeconomic status Women with a
• higher socioeconomic status and/or education tend to
• have fewer children and start childbearing after age 30 –
• both of which put them at higher risk.
• • weight Obesity or weight gain after menopause are risk
• factors.
• • genetic alterations Inherited alterations in the genes,
• called BRCA1 and BRCA2, account for about five to 10
• percent of all breast cancer cases.
• Other risk factors include:
• • oral contraceptive use
• • a diet high in saturated fats
• • physical inactivity
• • alcohol (more than one alcoholic drink a day)

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 ScreeningScreening
 Cancer screening exams are medical tests that are performed whenCancer screening exams are medical tests that are performed when
a person has no symptoms.a person has no symptoms.
 All women should be familiar with their breasts so that they willAll women should be familiar with their breasts so that they will
notice any changes and reportnotice any changes and report
 them to their doctor without delay. M. D. Anderson alsothem to their doctor without delay. M. D. Anderson also
recommends the following:recommends the following:
 •• Clinical breast exams every one to three years beginning at ageClinical breast exams every one to three years beginning at age
20.20.
 •• Yearly mammograms and clinical breast exams beginning at ageYearly mammograms and clinical breast exams beginning at age
40 and continuing for40 and continuing for
 as long as a woman is in good health.as long as a woman is in good health.
 M. D. Anderson breast cancer experts recommend that all womenM. D. Anderson breast cancer experts recommend that all women
practice “breast selfawareness”practice “breast selfawareness”
 (BSA) as part of the triad of breast cancer screening guidelines,(BSA) as part of the triad of breast cancer screening guidelines,
which includeswhich includes
 breast exams by physicians (clinical breast exams) andbreast exams by physicians (clinical breast exams) and
mammograms.mammograms.
 TipsTips
 ••

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 TipsTips
 •• Schedule a clinical breast exam at the time of or just before yourSchedule a clinical breast exam at the time of or just before your
regularly scheduledregularly scheduled
 mammogram.mammogram.
 •• If you are age 35 or older, ask your doctor to calculate your breastIf you are age 35 or older, ask your doctor to calculate your breast
cancer risk.cancer risk.
 •• Consider additional screening if you are at risk.Women atConsider additional screening if you are at risk.Women at
increased risk of breastincreased risk of breast
 cancer (e.g., family history, genetic predisposition, past breastcancer (e.g., family history, genetic predisposition, past breast
cancer) should talk to theircancer) should talk to their
 doctor about the benefits and limitations of starting mammogramsdoctor about the benefits and limitations of starting mammograms
earlier, having additionalearlier, having additional
 test (e.g., breast ultrasound or MRI) or having more frequent exams.test (e.g., breast ultrasound or MRI) or having more frequent exams.
 These recommendations are provided as a guide. If exam resultsThese recommendations are provided as a guide. If exam results
suggest cancer, more extensivesuggest cancer, more extensive
 diagnostic tests, such as an ultrasound or biopsy of the breastdiagnostic tests, such as an ultrasound or biopsy of the breast
tissue, should be conductedtissue, should be conducted

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 Reducing Your RiskReducing Your Risk
 You can take action to reduce your risk of developing breastYou can take action to reduce your risk of developing breast
 cancer. M. D. Anderson suggests:cancer. M. D. Anderson suggests:
 •• talking to your doctor about your use of oraltalking to your doctor about your use of oral
 contraceptives and hormonal therapycontraceptives and hormonal therapy
 •• maintaining your ideal weightmaintaining your ideal weight
 •• eating at least five servings of fruits and vegetableseating at least five servings of fruits and vegetables
 per dayper day
 •• following recommended screening guidelinesfollowing recommended screening guidelines
 •• exercising regularlyexercising regularly
 •• eliminating tobacco use and using alcohol in moderationeliminating tobacco use and using alcohol in moderation
 •• getting your breast cancer risk assessedgetting your breast cancer risk assessed
 •• if you’re at increased risk, talk to your doctor aboutif you’re at increased risk, talk to your doctor about
 medications that can reduce your risk of developingmedications that can reduce your risk of developing
 breast cancer.breast cancer.
 Take time to discuss your own risks with your health careTake time to discuss your own risks with your health care

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 Biopsy:Biopsy: a small sample of the suspicious area of thea small sample of the suspicious area of the
breast is removed for examination under a microscope.breast is removed for examination under a microscope.
Biopsies can be done in the following ways:Biopsies can be done in the following ways:
 Surgical biopsy:Surgical biopsy: an incision is made in the breast.an incision is made in the breast.
Surgeons locate the tumor by palpation or with the aid ofSurgeons locate the tumor by palpation or with the aid of
images from a CT scan, ultrasound or mammogram. Inimages from a CT scan, ultrasound or mammogram. In
anan excisional biopsyexcisional biopsy , the entire mass is removed. In, the entire mass is removed. In
anan incisional biopsyincisional biopsy , only a portion of the tumor is, only a portion of the tumor is
removed.removed.
 Fine Needle Aspiration (FNA):Fine Needle Aspiration (FNA): a thin, hollow needlea thin, hollow needle
is inserted into the breast to the tumor, and fluid andis inserted into the breast to the tumor, and fluid and
cells are removed from the tumor. While this test cancells are removed from the tumor. While this test can
help to determine if there is cancer present, it cannothelp to determine if there is cancer present, it cannot
determine if the cancer is invasive and additionaldetermine if the cancer is invasive and additional
biopsies may be needed if cancer is actually present.biopsies may be needed if cancer is actually present.
 Core biopsy:Core biopsy: a thicker needle is used to remove one ora thicker needle is used to remove one or
more small cylinder-shaped tissue samples from themore small cylinder-shaped tissue samples from the
tumor.tumor.

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 shaped tissue samples from the tumor.shaped tissue samples from the tumor.
 Diagnostic mammogram:Diagnostic mammogram: this procedure is similar tothis procedure is similar to
the mammogram used for screening, but provides morethe mammogram used for screening, but provides more
detailed images of the breast tissue. detailed images of the breast tissue.
 Magnetic Resonance Imaging (MRI):Magnetic Resonance Imaging (MRI): images ofimages of
the breast are created with powerful magnets thatthe breast are created with powerful magnets that
interact with a computer.interact with a computer.
 Ultrasound:Ultrasound: a special wand placed against the skina special wand placed against the skin
transmits sound waves, which bounce off breast tissuetransmits sound waves, which bounce off breast tissue
and are used create an image on a monitor. and are used create an image on a monitor.
 Sentinel lymph node biopsy:Sentinel lymph node biopsy: lymph nodes are olive-lymph nodes are olive-
sized glands which are part of a system that circulatessized glands which are part of a system that circulates
lymph fluid throughout the body. The lymphatic systemlymph fluid throughout the body. The lymphatic system
can also carry cancer cells from the tumor site to othercan also carry cancer cells from the tumor site to other
areas of the body. In breast cancer patients, the firstareas of the body. In breast cancer patients, the first
nodes to be affected are under the armnodes to be affected are under the arm

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Staging TNM SYSTEM
• Primary tumor (T)
• Tx: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis: (DCIS) Carcinoma in situ
• Tis: (LCIS) Carcinoma in situ
• Tis: Paget disease of the nipple with no tumor (Paget disease
associated with a tumor is classified according to the size of the
tumor.)
• T1: Tumor 2 cm or smaller in greatest diameter
– T1mic: Microinvasion 0.1 cm or less in greatest dimension
– T1a: Tumor >0.1 but not >0.5 cm in greatest diameter
– T1b: Tumor >0.5 but not >1 cm in greatest diameter
– T1c: Tumor >1 cm but not >2 cm in greatest diameter
• T2: Tumor >2 cm but not >5 cm in greatest diameter
• T3: Tumor >5 cm in greatest diameter
• T4: Tumor of any size, with direct extension to (a) the chest wall or (b)
skin only, as described below
– T4a: Extension to the chest wall, not including the pectoralis muscle
– T4b: Edema (including peau d’orange) or ulceration of the skin of the breast
or satellite skin nodules confined to the same breast
– T4c: Both T4a and T4b
– T4d: Inflammatory disease

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• Regional lymph nodes (N)
• Nx: Regional lymph nodes cannot be assessed (eg, previously
removed)
• N0: No regional lymph node metastasis
• N1: Metastasis in movable ipsilateral axillary lymph node(s)
• N2: Metastasis in ipsilateral axillary lymph node(s) fixed or matted,
or in clinically apparent ipsilateral internal mammary nodes in the
absence of clinically evident axillary lymph node metastasis
– N2a: Metastasis in ipsilateral axillary lymph nodes fixed to one another
or to other structures
– N2b: Metastasis only in clinically apparent ipsilateral internal mammary
nodes and in the absence of clinically evident axillary lymph nodes
• N3: Metastasis in ipsilateral infraclavicular or supraclavicular lymph
node(s) with or without axillary lymph node involvement, or
clinically apparent ipsilateral internal mammary lymph node(s) and
in the presence of axillary lymph node
– N3a: Metastasis in ipsilateral infraclavicular lymph node(s)
– N3b: Metastasis in ipsilateral internal mammary lymph node(s) and
axillary lymph node(s)
– N3c: Metastasis in ipsilateral supraclavicular lymph node(s)

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• Distant metastasis
• Mx: Distant metastasis cannot be
assessed
• M0: No distant metastasis
• M1: Distant metastasis

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 Table 2. TNM Staging System for Breast CancerTable 2. TNM Staging System for Breast Cancer

Open table in new windowOpen table in new window
 [ CLOSE WINDOW ][ CLOSE WINDOW ]
 TableTable
 StageTumorNodeMetastasesStageTumorNodeMetastases Stage 0TisN0M0Stage IT1N0M0Stage IIAT0Stage 0TisN0M0Stage IT1N0M0Stage IIAT0
T1T1
T2N1T2N1
N1N1
N0M0N0M0
M0M0
M0Stage IIBT2M0Stage IIBT2
T3N1T3N1
N0M0N0M0
M0Stage IIIAT0M0Stage IIIAT0
T1T1
T2T2
T3N2T3N2
N2N2
N2N2
N1-2M0N1-2M0
M0M0
M0M0
M0Stage IIIBT4M0Stage IIIBT4
T4T4
T4N0T4N0
N1N1
N2M0N2M0
M0M0
M0Stage IIICAny TN3M0Stage IVAny TAny NM1M0Stage IIICAny TN3M0Stage IVAny TAny NM1StageTumorNodeMetastasesStageTumorNodeMetastases Stage 0TisN0M0Stage IT1N0M0Stage IIAT0Stage 0TisN0M0Stage IT1N0M0Stage IIAT0
T1T1
T2N1T2N1
N1N1
N0M0N0M0
M0M0
M0Stage IIBT2M0Stage IIBT2
T3N1T3N1
N0M0N0M0
M0Stage IIIAT0M0Stage IIIAT0
T1T1
T2T2
T3N2T3N2
N2N2
N2N2
N1-2M0N1-2M0
M0M0
M0M0
M0Stage IIIBT4M0Stage IIIBT4
T4T4
T4N0T4N0
N1N1
N2M0N2M0
M0M0
M0Stage IIICAny TN3M0Stage IVAny TAny NM1M0Stage IIICAny TN3M0Stage IVAny TAny NM1

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THERAPIE :THERAPIE :
1.OPERASI.1.OPERASI.
2.CHEMOTHERAPIE.2.CHEMOTHERAPIE.
3.RADIASI.3.RADIASI.
4.HORMONAL.4.HORMONAL.

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PROGNOSA :PROGNOSA :
TERGANTUNG STADIUM.TERGANTUNG STADIUM.

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23. 6 JUN 10 FF6 JUN 10 FF 2323

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 Facing a mirrorFacing a mirror
 Stand before a mirror and compare both breasts for differencesStand before a mirror and compare both breasts for differences
in size, nipple inversion (turning in), bulging, or dimpling. Note anyin size, nipple inversion (turning in), bulging, or dimpling. Note any
skin or nipple changes, such as a hard knot orskin or nipple changes, such as a hard knot or nipple dischargenipple discharge..
 Inspect your breasts in the following 4 steps:Inspect your breasts in the following 4 steps:
– With yourWith your armsarms at your sidesat your sides
– With your arms overheadWith your arms overhead
– With your hands on hips - Press firmly to flex yourWith your hands on hips - Press firmly to flex your chestchest muscles.muscles.
– Bent forward - Inspect your breasts.Bent forward - Inspect your breasts.

 In these positions, your pectoral muscles are contracted, and aIn these positions, your pectoral muscles are contracted, and a
subtle dimpling of the skin may appear if a growing tumor hassubtle dimpling of the skin may appear if a growing tumor has
affected a ligamentaffected a ligament

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 Lying downLying down
 Right breastRight breast
and Left breastand Left breast
– Place a pillow under your right shoulder.Place a pillow under your right shoulder.
– Put your right hand under your head.Put your right hand under your head.
– Check the entire breast area with the finger pads of your left hand.Check the entire breast area with the finger pads of your left hand.
– Use small circles and follow an up-and-down pattern.Use small circles and follow an up-and-down pattern.
– Use light, medium, and firm pressure over each area of the breast.Use light, medium, and firm pressure over each area of the breast.
– Feel the breast with the surfaces of the second, third, and fourth fingers, movingFeel the breast with the surfaces of the second, third, and fourth fingers, moving
systematically and using small, circular motions from the nipple to the outersystematically and using small, circular motions from the nipple to the outer
margins.margins.
– Gently squeeze the nipple for any discharge.Gently squeeze the nipple for any discharge.

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 In the showerIn the shower
 A BSE can easily be performed while you're in the bathA BSE can easily be performed while you're in the bath
or shower. Some women discover breast masses whenor shower. Some women discover breast masses when
their skin is moist.their skin is moist.
– Raise your right arm.Raise your right arm.
– With soapy hands and fingers flat, check your right breast.With soapy hands and fingers flat, check your right breast.
– Use the same small circles and up-and-down pattern describedUse the same small circles and up-and-down pattern described
earlier.earlier.
– Repeat on the left breast.Repeat on the left breast.

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