3. INTRODUCTION
• Worldwide breast cancer is the most frequently diagnosed life
threatening cancer in women
• The leading cause of cancer deaths in women in developing countries
• Over the past 3 decades, extensive and advocacy driven breast cancer
research has led to extraordinary progress in the understanding of the
disease
4. INTRODUCTION
• Many early breast cancers are asymptomatic
• The general approach to evaluation of breast cancer has become
formalized as triple assessment
• The management of breast cancer is individualized
• Surgery and radiation therapy, along with adjuvant hormone or
chemotherapy when indicated, are now considered primary treatment
for breast cancer
5. EPIDEMIOLOGY
• The incidence of breast cancer increases with age
• In 2020, there were 2.3million women diagnosed with breast cancer
and 685,000 deaths globally
• Approximately 0.5-1% of breast cancers occur in men
• In the US, breast cancer accounts for 30% of all cancers in women
and is second only to lung cancer as a cause of cancer related death
in women
6. EPIDEMIOLOGY
• In a study by Afolaya, Ibrahim and Ayilara in 2012 on cancer patterns
in Ilorin which showed that breast cancer is the leading cause of
cancer in women (22.41%) followed by cervical cancer (13.14%)
• In a study by Adeniji et al in 2010 to determine the molecular subtype
of breast cancer results showed basal-like (25%), unclassified (24%),
luminal A (20%), HER2+/ER- (19%) and luminal B (11%)
10. AETIOPATHOGENESIS
RISK FACTORS
• Approximately half of breast cancer develop in women who have no
identifiable risk factor other than Gender and age (>40yrs)
• Family history (BRCA1 and BRACA2)
• Reproductive history (early menarche, late menopause, age at first
confinement, inter-pregnancy interval, duration of breast feeding)
• Obesity
• Alcohol
• Tobacco use
14. AETIOPATHOGENESIS
The Cancer Genome Atlas
Network (TCGA) confirms the
following 4 main breast tumor
subtypes, with distinct genetic
aberration
• Luminal A
• Luminal B
• Basal-like
• HER2-positive
15. PATHOLOGY
• Breast lump
• Nipple (retraction, deviation, destruction, discharge
• Peau d’orange
• Skin dimpling
• Breast ulceration
• Breast destruction
• Axillary/Neck swelling
17. CLINICAL FEATURES
• Breast lump
• Alteration is size, shape and appearance of breast
• Dimpling, redness, pitting, ulcer
• Change in nipple appearance
• Abnormal nipple discharge
• Constitutional symptoms
• Metastatic features
• Other swellings
18. DIFFERENTIALS
• Traumatic fat necrosis
• Fibroadenoma of the breast
• Chronic breast abscess
• Tuberculosis of the breast
• Mastitis
19. MANAGEMENT
• The management of breast cancer involves a multidisciplinary
approach involving the General surgeon, Onco-plastic surgeon,
anesthetist, nurses, radiologist, orthopedic surgeon, psychotherapist,
pulmonologist among others.
The aim of management is dependent on the stage of presentation
• Early disease aims at cure
• Late disease aims at palliation
21. MANAGEMENT
HISTORY
• Gender, Age, occupation, marital status
• Reproductive history
• Family history
• Hormonal therapy
• Exposure to radiation
• Personal history of breast or gynecology malignancy
• Alcohol
• Smoking
31. MANAGEMENT
TX: Primary tumour can not be assessed Nx:Regional nodes can not be assessed
T0: No evidence of tumour N0:Negative nodes
Tis: Carcinoma insitu N1: Mobile ipsilateral axillary node
T1: Tumour <2cm N2: Fixed ipsilateral axillary node
T2: Tumour 2-5cm N3: Fixed ipsilateral mammary, infraclavicular or
supraclavicular node
T3: Tmour >5cm Mx: Distant metastasis can not be assessed
T4: Tumour of any size with direct extension to the
chest wall or skin
M0: No Distant metastasis
T4a: Tumour with extension to the chest wall M1: Distant metastasis
T4b: Tumour with extension to the skin with ulceration,
edema, satellite nodules
T4c: T4a and T4b
T4d: inflammatory carcinoma
34. MANAGEMENT
• SURGERY
• CHEMOTHERAPY (CAF,CEF,ACT regimen)
• RADIOTHERAPY
• HOMORNAL THERAPY (SERMS and Aromatase inhibitors)
• IMMUNOTHERAPY
35. MANAGEMENT
Definitive Treatment
Ductal carcinoma insitu
• Typically segmental and unicentric, often multifocal
• nipple and subareolar region commonly involved
• Does not invade or cause metastasis.
40. MANAGEMENT
Definitive Treatment
Stage 3 disease
• Probability of distant metastasis is high
• Neoadjuvant chemotherapy
• In most clinical trials 3-4 cycles of doxorubicin-containing regimen
before surgery will reduce the tumor size and facilitate local excision in
> 80% of cases
• Clinical complete response in 10-20%
- only 2/3 of these will have pathologic CR
• Then XRT or surgery, mastectomy, followed by further chemotherapy
• Inflammatory breast cancer
- before combined modality therapy 5yr survival = 5%
- with combined modality therapy 35% disease free at 10yrs
41. MANAGEMENT
Definitive Treatment
Metastatic disease
• The majority of deaths are caused by growth of metastases
• Local recurrences are often associated with metastasis
• Not curable; palliation is the goal
• Median life expectancy 18-24 months
• Categories
- locoregional
- bone only
- visceral disease
- visceral crises
51. SPECIAL CASES
Paget’s Disease
• Prognosis depends on presence of invasive breast cancer and
axillary LN
• BCS can be offered
Pregnancy associated breast cancer
• surgery
• chemotherapy can be used in 2nd or 3rd trimester
• biochemical steroid binding assays for HR usually negative
• Tamoxifen should not be used
• Therapeutic abortion has not been shown to improve survival
52. SPECIAL CASES
MALE BREAST CANCER
• Due to usual central location
• Modified Radical Mastectomy + XRT
• Adjuvant chemo- and endocrine therapy
Endocrine therapy
• most are ER+
• Tamoxifen, progesterone, orchiectomy
55. FOLLOW UP
• Monthly Breast Self Examination
• Annual mammography of preserved/contralateral breast
• History and physical exam
• q 3-6mo x 3yrs
• q 6-12mo x 2yrs
• q yrly
• all women to have pelvic exam & pap smear
56. PROGNOSIS
Depends on
• Age
• Presentation
• Tumor size
• Axillary lymph node status
• Biologic subtype
• Availability, affordability and access to care
• Lymphatic/vascular invasion
• Histologic grade
• Comorbidity
57. PREVENTION
• Primordial: legislation
• Primary: Health education, screening, prophylactic mastectomy, BSO
+TAH
Secondary: early detection, timely diagnosis and comprehensive
management
• WHO global breast cancer initiative
• Reduce death by 2.5%/yr targets 2.5million reduction between 2020-
2040.
• Tertiary
59. CONCLUSION
• Breast cancer is a systemic disease
• Female gender and increasing age are notable risk factor
• Routine screening is essential for early detection
• Advance disease is associated with high morbidity and mortality
• Ignorance, poverty and religion is implicated for late presentation
• Surgery, chemotherapy, radiotherapy, hormonal and immunotherapy
are notable management option
61. REFERENCES
• Archampong EQ, NAAEDER SB, UGWU B. Baja’s Principle and
practice of surgery: The Breast. 5th Ed. Vol1, Chapter28, pg 505-536.
• Pavani C, John VK. Breast Cancer. Medscap, updated Apr 08, 2021.
• Breast cancer. WHO @ https://www.who.int/news-room/fact-
sheets/details/breast-cancer. March 26, 2021.
• Emeka Kesieme. Comprehensive Approach to Long cases in surgery.
Ephatha press,Edo, Nigeria. 1st Ed. 2013, Chapt. 2, Pg. 24-39
• Afolayan EAO, Ibrahim OOK, Ayilara GT. (2012). Cancer patterns in
Ilorin: An analysis of Ilorin Cancer Registry statistics. Tropical Journal
of health sciences. Vol.19 No.1
• Emeka Kesieme. VIVA in Surgical Principle and Operative Surgery.
Ephatha press,Edo, Nigeria. 1st Ed. 2013, Pg. 333-339
62. REFERENCES
• Snijesh VP, Manoj R.(2017). Breast Cancer Detection: Current Methods
and Roadmap to Personalized Medicine. Canc Therapy & Oncol Int
J.5(5): 555672. DOI: 10.19080/CTOIJ.2017.05.555672
• Adeniji KA, Huo D, Khramtsov A. et al. (2010).Molecular Profiles of
Breast Cancer in Ilorin, Nigeria. Journal of clinical oncology, Volume 28,
issue15.
• Al-fallouji MAR. Post Graduate Surgery: The Candidates guide. Breast
Surgery. 1998. 2nd Ed. The Bath Press PLC. Great Britain. Page 306-
313
