NPCDCS Cancer Diabetes and Cancer

1. Current Burden of
Breast Cancer
Prof Rajendra Prasad Ganguly
Dept of G & O
R G Kar Medical College
KOLKATA.

2. Breast Cancer Trends
• A woman diagnosed with breast cancer
every 3 minutes- adding to 1 million cases
each year
• WHO Estimates- 1.5 million by 2020
• Indian Scene- rising incidence-
–79,000 cases in 2001
–80,000 cases in 2002
–250,000 estimated by 2015
• International Agency for Research on Cancer

3. The Burden of Disease in India
• Increasing Incidence
• Low Awareness among doctors and
women
• Late presentation

4. Burden of Cancer in India
http://globocan.iarc.fr/Pages/fact_sheets_population.aspx
Cancer burden in India (2012,
in both sexes):
New cases: 1million
Deaths: 0.6 million
NCRP data:
Incident cases: 14 Lakhs
Prevalent cases: 38 lakhs
Deaths: 7 Lakhs
Cancers of Breast, cervix
and oral cavity together
constitute 34% of all
cancers.
Amenable to
prevention/early detection.
Estimated age-standardized incidence and mortality rates: both
sexes

5. Indian Scene
• Urban Incidence- 25 to 30 new cases per
100,000 women per year
• Rural Incidence- 6 new cases per 100,000
women per year
• Highest in Mumbai, Chennai and Delhi
• 1 ,25,000 new breast cancer cases arise
each year in India

6. TIME Surveys
Late Presentation in India
• Half of all Indian women with disease go
entirely without treatment
• South Africa - 5% of cancers in early stage
• USA - 50% in Early stage
•India - <10% Early stage

7. Screening
» Use of simple tests across a healthy population in order to
identify individuals who have disease, but do not yet have
symptoms.
» Screening in context of cancers aims to detect precancerous
changes, which, if not treated, may progress to cancer.
» A screening program is effective only if there is a well
organized system for follow-up and management of screen
detected lesions.

8. Rationale of screening for Breast, Cervical and
Oral cancers
Most prevalent cancers- public health priority
High cost of treatment – mostly out of pocket expenditure
Amenable to prevention ( oral and cervix ) or early detection (breast)
Simple, sensitive and cost effective tools available for screening or early
diagnosis.
Standard protocols are in place for management of screen detected
precancerous and cancerous lesions
High cure rates if detected in early stages

9. Screening Strategy
Type of
Cancer
Age of
beneficiary
Method of Screening Frequency
of screening
Oral 30 -65 years Oral Visual Examination
(OVE)
Once in
5years
Cervical 30-65 years Visual Inspection with
Acetic acid (VIA)
Once in
5years
Breast 30-65 years Clinical Breast
Examination (CBE)
Once in
5years

10. Referral of screen positive cases
Type of
Cancer
Method of Screening If positive
Oral Oral Visual Examination
(OVE)
Referred to Surgeon/Dentist/ENT
specialist/Medical officer at CHC/DH for
confirmation and biopsy.
Cervical Visual Inspection with
Acetic acid (VIA)
Referred to the CHC/DH for further
evaluation and management of pre-
cancerous conditions where trained
gynecologist is available.
Breast Clinical Breast
Examination (CBE)
Referred to Surgeon at CHC/DH for
confirmation using a Breast ultra sound
probe and biopsy.

11. Breast Cancer- commonest in Delhi
1212 cases 2002
1309 cases in 2003

13. Milk Ducts and Glands

14. 9
What is Cancer ?
• Uncontrolled growth of cells
• Purposeless
• Undisciplined like terrorist
• Robs all the food that you eat and continues
to grow till host dies.
9

15. Normal and Cancer cells

17. Schedin Nature Reviews Cancer 6, 281–291 (April 2006) | doi:10.1038/nrc1839

18. Breast cancer

19. 4 Stages

20. Modalities for Breast Imaging
• Mammography is the primary modality
• Complimentary modalities
–Ultrasound
–MRI
–PET-CT

21. Mammography
• X-ray of breast
• Modified to evaluate soft tissues with higher
contrast and spatial resolution
–Low energy x-rays
–High resolution films
–Compression of the breast

22. Basic Views
• Medio-lateral oblique Cranio-caudal

23. Basic Views
• Medio-lateral oblique (MLO)
Cranio-caudal (CC)

24. Masses

25. Calcifications
•

26. BIRADS Classification of Mammographic
Lesions
•

27. Breast Ultrasound
• Primary imaging modality for women below
35 years
–Mostly benign lesions, satisfactorily detected and
characterized by ultrasound
• Dense breasts
• Differentiation of cystic Vs solid mass
• Duct discharge

28. Cysts
• Simple cysts
–Thin walls
–Anechoic contents
• Complex cysts
–Abscess, Galactocele, ca
• USG diagnosis of simple
cyst is important
–No biopsy, treatment or
follow-up is required

29. Masses
• Benign
–Round, oval
–Well defined walls
–Distal enhancement
• Malignant
–Irregular
–Poorly defined walls
–Distal shadowing

30. Duct Discharge
• Ultrasound
• Ductography

31. Breast MRI: Indications
• Mammography
inconclusive/ not possible
• Preoperative staging
• To differentiate scar and
recurrent tumor
• Screening of genetically
high risk women
• MRI should not be used
as a substitute to
mammography or biopsy

32. PET -CT
• Provides morphological
and metabolic information
• High sensitivity and
specificity
• Indications
–Staging (both local and
distant)
–Occult primary
–Predict response to
chemotherapy
–Recurrence

33. So What Causes Cancer?
• We DO NOT KNOW
• We know some conditions which increase
risk – called RISK FACTORS
• We also know some conditions that can
prevent cancer- PROTECTIVE FACTORS
28

34. Factors Increasing the risk
• Hormones: Hormone replacement
therapy (HRT) - Magnitude of Effect for
Combination Therapy: Approximately a
24% increase in incidence of invasive
breast cancer if a lady takes HRT for 10
years continuously

35. Ionizing radiation
• Exposure of breast to ionizing
radiation increases risk of
developing breast cancer, starting
10 years after exposure and
persisting lifelong. Risk about 6
times , depends on dose and age at
exposure, with the highest risk
occurring during puberty.

36. Obesity
• Obesity increases breast risk
in postmenopausal women
• Comparing women weighing
more than 82.2 kg with those
weighing less than 58.7 kg, the
relative risk (RR) is 2.85

37. Alcohol
• Exposure to alcohol increases risk
in a dose-dependent fashion
• RR for women consuming 4 drinks
per day compared with nondrinkers
is 1.32
• RR increases by 7% for each drink
per day

38. Genetic Risk
• Women who inherit gene mutations
BRCA1 & BRCA2 have an increased risk.
• Family history: 30% life time risk
• Family history+ gene mutation= 80% or
more life time risk by age 70 years

39. Protective Factors - Breast Cancer
• Exercise
• Exercising strenuously for more
than 4 hours per week reduces
risk
• RR reduction is 30% to 40%.
• The effect may be greatest for
premenopausal women of normal
or low body weight

40. Early pregnancy
• Women having full-term
pregnancy before age 20 years
have decreased risk.
• 50% decrease in breast cancer
compared to nulliparous women
or those who give birth after age
35 years.

41. Preventive Mastectomy
• Bilateral mastectomy reduces
the risk in women with a
strong family history.
• Risk is reduced as much as
90%

42. Preventive Oophorectomy
• Oophorectomy in women with
BRCA gene mutations lowers
risk.
• Breast cancer incidence is
decreased by 50%. ( same as
Tamoxifen)

43. Primary Prevention
• Reduce weight
• Eat less animal fat and red meat
• Increase physical exercise 4 hrs/ week
• First child below 20-25 yrs breast feed
• Chemoprevention- Tamoxifen 20 mg for 5
years
• Risk Reduction Mastectomy or
Oophorectomy

44. Breast Cancer early detection
• Mammography
• Clinical Breast Examination- CBE
• Breast self examination- BSE

45. Screening for Breast Cancer
• Screening by Mammography
Mammography in women aged 40 to 70
years decreases breast cancer mortality. The
benefit higher for older women, because
their breast cancer risk is higher.
•

46. Screening by Clinical Breast
Examination- CBE
•
• Screening by clinical breast examination
reduces breast cancer mortality.
• Breast cancer mortality same (for
women aged 50 to 59 years) CBE alone
vs CBE + mammogram ( Canadian
study)

47. Screening by Breast Self-
Examination (BSE)
• BSE increases awareness of a lady
about her breast health and
changes with menstrual cycle,
pregnancy, lactation and age
• Teaching breast self-examination
does not reduce breast cancer
mortality.

48. Breast Cancer
BSE

49. Breast Self Examination
.

50. Breast self examination
BSE
Things change if
women take
charge of their
own health !

51. anitadhar_bhan@hotmail.com
Breast
conservation
surgery
Why BSE?
It can avoid
mastectomy

52. Why to do the Breast Self-Exam?
In India many women
come for a check up
only when the breast lump
becomes large, with an ulcer
or starts bleeding.
Do not hide the
problem for a long period
till it is late for any
cure

53. Early diagnosis
• Early detection
Good Prognosis with
breast preservation
90% cancers detected
by the lady herself

54. The Five Steps
How to do the Breast Self-Exam?

55. Step 1
• Look in mirror with
shoulders straight & arms
on hips.
• Look for:
–Symmetry in size, shape, and
color
–Nipple/ areola retraction or
deviation
–dimpling, puckering

56. Nipple retraction in left breastChange in colour over the skin
Lump with blood discharge Orange peel
appearance

57. Step 2
• Raise arms and
look for retraction
–Indrawing of
nipple or dimpling
of skin

58. Step 3
• Feel breasts lying down on a hard bed, using
right hand feel left breast
• Use firm, smooth touch with the 3 fingers
• Cover the entire breast from clavicle to
inframammary crease, midline to midclavicular
line

59. Step 4
• Gently roll nipple
between finger
and thumb and
check for nipple
discharge (blood
or watery
discharge
suspicious. )

60. Lay down and feel
On your back On your side

61. Overlapping circlesUse pad of your 3 fingers

62. Circles
Lines
Wedges/clock-like

63. Step 5
Feel breasts while bathing
as skin is wet and slippery,
Higher sensitivity

64. Who should do the breast self
examination?
All women aged 20 and above. It should
continue throughout the life.

65. When to do the Breast Self-Exam?
• 2 or 3 days after period ends. At this time
breasts are soft and supple and you are more
likely to find a lump
• After menopause pick a certain day-such as the
first day of each month or birthday
• If you are taking hormones- 1-2 days after
withdrawal bleeding

66. How often should I do BSE?
• Once a month

67. If examination reveals any change in
your breast, a lump , pain or nipple
discharge –blood or watery – See
your doctor
for investigations if required.
Report early

68. Summary
• BSE is an important aspect of breast health
awareness
• BSE is easy to perform and teach
• BSE can pick up changes in the breast that a
women can find herself at the earliest
• In India, BSE can help to identify cases in
early stages

69. Breast Health Awareness Campaign

70. Don’t Wait till Late

71. Primary Prevention
• Reduce weight
• Eat less animal fat and red meat
• Increase physical exercise 4 hrs/ week
• First child below 20-25 yrs breast feed
• Chemoprevention- Tamoxifen 20 mg for 5
years
• Risk Reduction Mastectomy or
Oophorectomy

72. Suggested Websites and readings
• www.cancer.gov National Cancer Institute
• www.cancer.org American cancer Society
• www.yourcancerrisk.harvard.edu/ Risk
assessment tool from Harvard University
• www.cancer.gov/bcrisktool/ Risk tool
• www.imaginis.com/breasthealth/earlydetectio
n.asp for BSE and information
• http://healthy-india.org for healthy life style

73. Spread the Word

74. Conclusion
• Breast Cancer increasing
• Be Aware of Breast Health
• Teach Breast self examination to all
mothers and sisters
• Early detection helps( Catch the
thief early) in good control

75. Thank You

76. The Spectrum of Breast
Diseases
• Benign:
• Pain,
• Lump(iness) diffuse- adolescent, gestational, male
• Nipple discharge
• Cancer
• Ductal 90%
• Lobular 5%
• Others 5%

77. The Burden of Benign Breast
disease
• Very Common in all communities
• 9 out 10 cases with breast problem
have benign disease
• Ill understood and poorly treated

78. Hormonal Control• Estrogen
– induces duct development
– stromal development
– increased vascularity (anovulatory cycles).
– Deposition of breast fat
• Progestrone
– Lobulo- alveolar development and duct branching.
– Proliferation and Secretion in lobules
– Swelling of breast due to proliferation and increased fluid
• Prolactin - milk secretion in primed breast,
• Inuslin, steroids, growth hormone - minor role.

79. Terminal Ductal-Lobular Unit

80. The TDLU Concept
• Terminal Ducto-lobular Unit - the
functional unit
• Hormone responsive
• Most breast diseases arise in TDLU- pain,
benign lumps, cancer

81. Hormonal Basis of ANDI
• Cyclic changes in Estrogen &
Progesterone
• Cell Proliferation
• Fluid retention with fat
• Increased breast volume in the
luteal phase
• Varied target organ response

82. Breast Development
10-12yr 14-16yr 16-
18yr
• Breast bud
elevation
• Growth &
protrusion of nipple
• Elevation of
secondary
areolar mound
• Regression of
areola.

83. Early reproductive
15-25 years
•Lobular
development
•Stromal
development
•Nipple eversion
•Fibroadenoma
•Adolescent
hypertrophy
•Nipple inversion
Mature
25 – 40 years
•Cyclical menstrual
change
•Epithelial
hyperplasia of
pregnancy
•Cyclical Mastalgia
•Nodularity
•Discharge
Involution
35 – 55 years
•Lobular involution
•Duct involution
• Macro and
microcyst
• Duct ectasia
• Nipple retraction

84. Patient Care

85. Approach to Mastalgia
• Detailed clinical history and exam, relation
with menses, contraceptive, pregnancy &
lactation
• Breast & Pelvis ultrasound, Mammogram
• Reassurance- 85% control
• Breast Support Garment
• Hormonal agents : Tamoxifen, Danazol,
Bromocriptine, Centchroman
• Anti-inflammatory gel massage- Diclofenac

86. Breast Pain Chart
Cyclical mastalgia with premenstrual exacerbation

87. Support Garments
• Relief in pain by
providing support to
stretched Cooper’s
suspensory ligaments

88. Drug Therapy for
Mastalgia
• Drug of Choice-Tamoxifen- 10 mg daily
for 3 months
• Response- 98% for cyclical, 56% noncyclical
• Side effects mild ; 50% - hot flashes, vaginal discharge , irregular periods

89. Drug Therapy of Mastalgia
• Danazol- 100 – 300 mg
•Response 70% good control
•Side effects – 25% wt gain, hair growth
• Evening Primrose oil- 6 capsules
• Response 2/3rd good control
• Side effects minimal- 4%
• No benefit over placebo (Srivastava et al, Breast 2007)

90. Centchroman/ Ormeloxifene
SAHELI
• Synthesized at the Central Drug Research Institute,
Lucknow
• Marketed in India since 1992
• Included in the National Family Welfare Programme
in 1995 as an Oral once a week Pill

92. Pain Relief with Centchroman vs. Danazol

93. Regression of Nodularity with Centchroman vs.
Danazol

94. Evidence Based Therapy of
Mastalgia
• First Meta-analysis of randomized trials
• Tamoxifen, Danazol, Bromocriptine,
Evening Primerose oil

100. Lactational Mastitis
• 3% to 33% of all feeding mothers
• Principles of Therapy: Antibiotics –
Erythromycin for 5 to 7 days; effective in
alkaline pH of milk- Penicillins inactive
• Continue Breast feeding
• Massage or Stripping to empty the milk
• Cold Compression with Cabbage leaves

101. Cold Cabbage Leaf
Compresses
• Chilled Cabbage leaf
• Apply on inflammed breast under the bra
• 2 hours on ; 4 hours off
• www.kellymom.com/cf/concerns/mom/eng
orgement.html#cabbage
• ABC of Breast Diseases- JM Dixon BMJ
1994;309:946- October 1994
• www.bmj.com/cg/content/full/309/6959/946

102. Lactational Mastitis
• Aspirate the Pus
• Do not Incise
rate the Pus
NOT INCISE

103. Catheter Suction Drainage of Breast
Abscess
An effective method of drainage of puerperal breast abscess by
percutaneous placement of suction drain Tewari, Mallika; Shukla, H.
Indian Journal of Surgery , November 1, 2006

104. Discrete LumpsTriple Assessment
• Clinical Evaluation: history & thorough exam
• Breast Imaging
• Ultrasound for all
• Mammogram >35 yrs
• MRI >25 yrs for family history, BCT
• Cytology or Histology

105. Large Core Needle Biopsy (Trucut)
• Image guidance
• 14 G Biopsy Gun
• Higher accuracy than cytology
• Grade, Type of tumour
• Estrogen, Progesterone & HER
2/neu receptors
• Mandatory before
chemotherapy

106. Impalpable Lesions
• Stereotactic Biopsy
• Wire Guided Excision
• Haematoma guided excision

107. Wire Guided Excision
for Impalpable lesion

108. Haematoma Guided Removal of
Impalpable Lesion

109. Magnetic resonance breast imaging with
Gadolinium contrast
• Meta-analysis of 2600 cases
• 16% more lesions identified,
missed on mammogram and
ultrasound
• 8% WLE changed to
Mastectomy
• 11% WLE became more
extensive WLE
• Helps in finding multicentric or
multifocal disease in both
breasts - J. Clinical Oncol
July2008

110. Benign Lumps: Fibroadenoma
• Centchroman- 33%
regression vs 3% in
control
• Enucleate in young girls
• Excise in
• >30 yrs
• Giant fibroadenoma>5cm
• Phylloides Tumour

111. Breast Carcinoma
• Discuss Plan of Therapy with:
• Oncologist
• Relatives
• Pathologist
• Radiologist
• Breast Care nurse /volunteer

112. Mastectomy
• Patient’s DESIRE
• Large tumours>4cm after chemotherapy
• Multicentric, Multifocal
• Extensive Ductal Carcinoma in Situ
• Extensive microcalcification
• Lymph node positive

113. Pre-op Chemotherapy
• Pathological complete regression(pCR) in 26% with
Docetaxel + Adriamycin+Cyclophosphamide NSABP-B18 trial
• Women with pCR enjoy 75% Disease free survival at 9 yrs
• Breast conservation possible with sentinel node biopsy

114. • Patient’s DESIRE
• Tumour < 4 cm
• Single tumour in one quadrant
• Radiotherapy manadatory
• Explain risk of higher local recurrence (1% /year)
and higher risk of death
• Preventing 4 Local recurrences saves 1 life
• Oxford overview Early Breast cancer trialist
Collaborative group,Lancet 17 Dec

115. Wide Local Excision
How wide is “wide”?
• Veronesi – took 2-3 cms margin for
quadrantectomy
• Holland et al- 43% tumor foci within 2
cms of primary, 10% within 4 cm
• Morimoto et al – 32% within 2.6 cms
from primary tumor

116. Techniques of Breast Conservation
• Elliptical Radial Excision
• Sector Excision with peripheral approach
• Dermoglandular Nipple Areola Complex Flap
• Central Excision with Purse String Closure
• Repair with Flaps
• Mini Latissimus Dorsi flap
• Rhomboid flap

117. Management of Axilla
• Assessment: Clinically incorrect
• Ultrasound and Fine Needle Aspiration Cytology
• PET scan
• Sentinel Node mapping
• Axillary Sampling

118. OUQ 2.5 cm Tumour
Quadrantectomy
+SLNB

120. Lateral Thoracodorsal Flap

121. Oncoplasty for 11mm OUQ Tumor

122. Mini-latissimus Dorsi
Flap

123. Reconstruction: free deep inferior
epigastric fasciocutaneous flap

124. Breast conservation for
LABC

127. Asymmetry
of breasts

129. Ill Placed Incisions

130. Ill Placed Incision
Nipple Areola complex
pulled up

131. Research

132. Sentinel Node concept
• Sentinel = a guard, one who
keeps watch or a sentry
• The first node in the regional
lymph node basin that drains
the primary tumor.
Most often, it is a cluster of LNs.

133. The Sentinel Node Concept

134. sentinel node biopsy
• Combination of blue
dye and Isotope
• Biopsy under local
anaesthesia (PRILOX)

136. Sentinel Lymph Node
Biopsy
• SN reliably predicts
regional nodal status
in breast cancer
• Excellent staging
procedure as it permits
focused HPE analysis
• May avoid axillary
node dissection

137. Sentinel Lymph Node Biopsy (validation)
• May 1996 till September 2008 ,523 clinically node negative, early breast cancer
patients. Sentinel node biopsy followed by full axillary dissection
• 267 underwent combined technique
• 256 underwent blue dye technique alone
• Identification 91.3%(253/267) for combined technique, 87.8%(225/256) for
blue dye alone
• The sensitivity= 91.5%(141/154)
• False negative=8.4%(13/154)
• negative predictive value = 91.5% (141/154)
• Accuracy = 97.2% (465/478)

138. Second Echelon
Sentinel Node in
Breast cancer
• Predicts Involvement of higher echelon of nodes in
axilla
• It may help select patients for further therapy after
sentinel node is found positive
• Bassi, et al , Indian J Cancer 2006

139. Reduction mammoplasty for
Gynaecomastia

140. Education

141. Training of doctors
• CME Breast disease management
• Screening methods Breast health
awareness
• School girls training

142. Training in Breast Cancer
Choice of
Surgery
Outcome
SLNB Re-resection
Methods
Attitude of Trainees
Applicability
Preference
Expectations

143. Summary -Benign
Breast Disease
• Pain & Lumpiness most common
• Exclude cancer
• Antiestrogen Tamoxifen 10 mg OD or
Centchroman 30 mg OD for 3 months

144. Summary-Cancer
• Triple assessment with image guided core
biopsy
• Planning by team
• Respect Patient’s desire more than science
•

146. Nipple Discharge
• Major Mammary Duct
Excision
• Srivastava et al

147. Milan Trial I,1973-1980, 701
patients, 10-13 year follow up
Treatment
Halsted
( N=349)
QUART
(N=352)
Local
recurrences
7 (2%) 13(3.6%)
Distant
metastases
76(21%) 71(20%)

149. Inheritance susceptibility
• Women who inherit gene mutations associated with
breast cancer have an increased risk.
• Magnitude of Effect: Variable, depending on gene
mutation, family history, and other risk factors
affecting gene expression.
• Family history: 30% life time risk; Family history+
gene mutation= 80% or more life time risk by age 70
years
• Study Design: Cohort or case-control studies.
• Internal Validity: Good.
• Consistency: Good.

159. Milan Trial II, 1985-1987,
705 patients
5 years follow up
Treatment QUART (N=360)
TART
(N=345)
Local recurrence 11(3%) 28(8%)
Metastases 43(12%) 42(12%)
Wide margins of at least 2 cms reduces LR

160. Milan Trial III, 1987-1989,567
patients, 6 years follow up
Treatment
QUART
(N=292)
QUAD
(N=275)
Local recurrence - 13%
Metastases 10(3%) 10(3.6%)
Radiotherapy mandatory for BCT

161. Flap thickness