Breast Cancer Management Update (2016)

Consultant Breast Surgeon ‫الثدي‬ ‫جراحة‬ ‫استشاري‬
Education & Training Director
Al Hammadi Hospital ‫الحمادي‬ ‫مستشفى‬
Riyadh, KSA ‫الرياض‬,‫السعودية‬ ‫العربية‬ ‫المملكة‬
2016
BREAST CANCER MANAGEMENT
UPDATE
Dr. Mohamad Al-Gailani FRCS ‫د‬.‫الكيالني‬ ‫محمد‬

Outline:
Breast Cancer Management Update
Facts about Breast Cancer
Clinical Presentation
Family History
Treatment: Surgery
Adjuvant Treatment
Summary & Conclusion
2Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

BREAST CANCER FACTS
• Breast cancer is the most common cancer in women.
• It is the second leading cause of death by cancer in
women next to lung cancer.
• A girl born today has a cumulative 1:8 risk of developing
breast cancer during the course of her life.
• Every 3 minutes a woman is detected to have breast
cancer. 3Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

World Health Organisation (WHO)
• Breast Cancer is among the leading causes of morbidity and
mortality worldwide.
• Approximately 14 million new cases and 8.2 million cancer related
deaths per anum.
• The number of new cases is expected to rise by about 70% over
the next 2 decades.
• Annual deaths from breast cancer > half a million
Riyadh, KSA

Breast Cancer
in
THE KINGDOM Of SAUDI ARABIA
(KSA)
• Incidence about 20 per 100,000 women
• Tops the list of the most common cancers in women by a rate of about
28%
• The predicted rate of breast cancer incidence will be more than
quadruple in the Middle East region during the next twenty years.
• Presents in a Younger age group, average around 48 years of age, a
decade younger than in the west.
• Around 73% of patients consult their doctor at an Advanced Stage.
• Mammographic Breast Screening uptake is poor despite adequate
facilities.
Riyadh, KSA

6
October
2016
For Women from the age of 40 and above…
Have you ever had a screening
Mammography?
Yes 16%
No, I don’t think it is essential
34%
I don’t know where the screening centres are
50%
2,846 votes
Final Results
October
2016*
Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA
*MOH Twitter account questionnaire, October 2016

Fungating
Breast Cancer
Lymphoedema
New
Contralateral
Cancer
“Peau d
’Orange”
The Ugly Reality of Incurable Breast Cancer
Riyadh, KSA

BREAST CANCER RISK FACTORS
(* Modern Life Influences)
• Age (Y): 80 1:8, 50 1:50, 40
1:200, 30 1:2,500
• Family History: 10% BRCA1,
BRCA2
• Total Number of Menstrual
Periods:
Early Menarche < 12
Late Menopause >55
• Late first childbirth* >30
• Not had children*
• Not Breast Fed*
• HRT*: > 10 years 66%
• Obesity*: 30%
• Alcohol*: 12%
• Other factors: Smoking, OCP?,
Deodorants?, Diet?,…
Riyadh, KSA

BREAST CANCER
CLINICAL
PRESENTATION
Riyadh, KSA

WARNING SIGNS OF
BREAST CANCER!
1. Discrete Lump in a patients >30
2. Ulceration, Skin Nodule, Skin Distortion (Dimpling)
3. Nipple Eczema (Paget’s Disease)
4. Recent Nipple Retraction or Distortion (< 3 months)
5. Unilateral Bloody Nipple Discharge
Riyadh, KSA

11
BREAST CANCER CLINICAL PRESENTATIONS
BREAST LUMP NIPPLE INVERSION SKIN DIMPLING SKIN PUCKERING
BLOODY NIPPLE
DISCHARGE
NIPPLE ECZEMA AXILLARY LUMP INFLAMMATORY
CANCER
Riyadh, KSA

BREAST CANCER SYMPTOMS WITH A
SIGNIFICANT POSITIVE PREDICTIVE VALUE (> 3%)
Complaint Positive Predictive Value (PPV) %
Breast Lumpiness 2.6
Breast Pain 1.6
Breast Mass/ Discrete Lump 10
Riyadh, KSA

13
FAMILY HISTORY
Breast Cancer
Riyadh, KSA

Breast Cancer Family History
• 90% of Breast Cancer is Incidental.
• 10% could be Familial.
• Significant Family History = 3 or more Relatives, One
First Degree, Young age, +/-Ovarian Cancer
• Average Risk: One 2nd or 3rd Degree Relative
• Moderate Risk: In-between
Riyadh, KSA

High (Significant) Risk Surveillance
(Predicted Lifetime Risk Assessment >30%)
•Counselling & encourage Breast Self Exam
•Annual MRI from age 30-49
•Annual mammography from age 40
•Genetic Testing if (>30% BRACA Carrier
Probability) 15Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

BRACA Gene Carriers
• Breast cancer risk up to 80%
• Ovarian cancer risk up to 50%
• Available options:
1. Surveillance for life
2. Chemoprevention: Tamoxifen & Raloxefine
3. Risk Reducing Mastectomy with Immediate
Reconstruction
4. Prophylactic Laparoscopic Oophorectomy 16Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

BREAST CANCER
TREATMENT
SurgeryBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

The Multi Disciplinary Team (MDT) Meeting
• A regular meeting (usually weekly) of a group of
specialists of different modalities treating a certain
condition and discussing best management plans
for the patient.
• Ensures (Face to Face) effective discussion of every
case from all aspects of management by all
specialities involved. 18Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

Composition of the
Breast Multi Disciplinary Team (MDT)
• Surgeon
• Oncologist
• Radiologist
• Pathologist
• Breast Care Nurse
• Geneticist?
• Plastic Surgeon?
Riyadh, KSA

Breast Conserving Surgery
(Screen Detected Breast Cancer)
Marker (Wire)-Guided Wide Local Excision
Riyadh, KSA

Breast Conserving Surgery
• Small tumour relative to breast size
• No difference in long term survival or local
recurrence rate compared to mastectomy
• Highest achievable cure rate (up to 95%)
• Requires postoperative Radiotherapy
Riyadh, KSA

MASTECTOMY
• Indications:
Unfavourable (Tumour:
Breast Size)
Multicentric Breast Cancer
Patient Preference
• Types:
• Simple Mastectomy
• Skin Sparing with
Immediate Reconstruction
• Skin & Nipple Sparing with
Immediate Reconstruction
Riyadh, KSA

Breast Reconstructive
Surgery
Riyadh, KSA

24
Latissimus Dorsi Myo
Cutaneous Flap
Skin Sparing Mastectomy
with Implant & ADM
Acellular Dermal Matrix
(ADM)
Breast Implants
Riyadh, KSA

Case 1
Right Skin Sparing Mastectomy & Immediate Recon
Latissimus Dorsi (LD) Flap + Implant
25
Right Nipple
Reconstruction Left Symmetrisation
Reduction
Op 1
Op 2
LD Muscle Harvest Wise Pattern Skin Sparing
Mx.
Riyadh, KSA

Case 2
Left Skin Sparing Mastectomy +
ADM Implant Immediate Reconstruction
Riyadh, KSA

Case 3
Left Skin & Nipple Sparing Mastectomy +
Immediate Reconstruction + ADM & Implant
Riyadh, KSA

Case 4
Right Delayed LD Reconstruction + Implant
Left Symmetrisation Reduction
28
Pre
Op
Pos
tOp
Riyadh, KSA

Sentinel Node Biopsy (SNB)
29
THE FIRST LYMPH NODE THAT DRAINS THE
BREAST
Riyadh, KSA

SENTINEL NODE BIOPSY
CONCEPT
Technitium99
& Blue Dye
Riyadh, KSA

SNB
Subareolar
injection
site
Ant. Oblique View Lateral View
SCINTIGRAPHY
Riyadh, KSA

“Europrobe” Gamma Finder
Riyadh, KSA

Removing the “Hot & Blue” Sentinel Node Measuring
Radioactivity
Ex Vivo
Riyadh, KSA

Adjuvant Therapy
Riyadh, KSA

Long-term Risk of Breast Cancer Recurrence
Remains High
0
0.1
0.2
0.3
0 1 2 3 4 5 6 7 8 9 10 11 12
Recurrencehazardrate
Years
ER– (n=1305)
ER+ (n=2257)
35
Plateau 1% per annum
Highest first 5 years
Riyadh, KSA

Adjuvant Chemotherapy
To Give or Not to Give?
•Adjuvant Chemotherapy or Hormonal
therapy reduces the risk of distant
metastases by approximately 30%.
•However 70-80% of patients receiving this
treatment would have possibly survived
without it! 36Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

Adjuvant
Chemotherapy
NO Adjuvant
Chemotherapy
Ki67, Oncotype
DX
37
NPI=
Size (cm)x0.2+Grade+LN
Riyadh, KSA

Radiotherapy (RT)
• Following Breast Conservation Surgery:
• RT 3 week course, 5 days a week
• Following Mastectomy:
• RT if large tumour (>4cm) or heavy axillary lymph
node involvement (>4 lymph nodes)
Riyadh, KSA

Hormone Treatment
• 80% of breast cancers are hormone receptor positive
• They will benefit from 5 years of hormone treatment
• They have the extra benefit of protecting the
contralateral breast
• Available hormone treatments include:
Tamoxifen
Anastrozole
Letrozole
Exemestane 39Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

Guidelines for Treatment of Breast Cancer
Adjuvant Hormone Treatment
Pre-Menopausal:
• Tamoxifen for five years.
Post-Menopausal:
• Good risk (NPI < 3.4): Tamoxifen for 5 years
• Intermediate risk patients (NPI 3.4-5.4):
Tamoxifen for 2-3 years followed by an AI to
complete 5 years treatment
• High risk patients (NPI > 5.4 or HER2+):
An AI from the outset for 5 years
*All patients with a recent history of thromboembolic disease or on long-term anticoagulation should
receive an AI in preference to tamoxifen.
Riyadh, KSA

Guidelines for Treatment of Breast Cancer
Extended Adjuvant Hormone Treatment
(beyond 5 years)
• An AI (usually Letrozole) extended adjuvant treatment for 2
years
• In patients considered at continuing significant risk for relapse
(e.g. Node positive)
• Completed 5 year course of Tamoxifen
Riyadh, KSA

HOW TO IMPROVE BREAST CANCER
SURVIVAL?
Breast screening (Currently 16% uptake).
Public Awareness & Breast Self Examination.
Lifestyle changes: Obesity, HRT, Smoking,
Breast Feeding.
High Risk Family History women:
Chemoprevention with Tamoxifen & Raloxifene.
Risk Reducing Mastectomy + Immediate
Reconstruction.Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA
42

Summary
• Breast cancer is common and increasing in
incidence in KSA.
• Women are more likely to present at an advanced
stage.
• Breast screening is available, but uptake remains
poor.
Riyadh, KSA

Conclusion
• Every woman should be Breast Aware and come
forward for regular Screening Mammography
from the age of 40 every 2 years.
• Public Health awareness efforts should be
intensified and directed towards women and their
families. 44Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS
Riyadh, KSA

45
Dr. Mohamad Al-Gailani ‫د‬.‫الكيالني‬ ‫محمد‬
Consultant Breast Surgeon ‫الثدي‬ ‫جراحة‬ ‫استشاري‬
Fellow Royal College of Surgeons England ‫الملكية‬ ‫الجراحين‬ ‫كلية‬ ‫زميل‬,‫انكلترا‬
Member British Association Breast Surgery (ABS)
Member British Association Surgical Oncology (BASO)
Al Hammadi Hospital ‫الحمادي‬ ‫مستشفى‬
www.alhammadihospital.com
Riyadh, KSA

Breast Cancer Management Update (2016)

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