Conferencia De Cáncer De Seno Al PúBlico

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  • Lung cancer is, by far, the most common fatal cancer in men (32%), followed by prostate (10%), and colon & rectum (10%). In women, lung (25%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death.
  • The age-adjusted death rate from all cancers combined stabilized from 1998 to 2000, after decreasing from 1990 to 1998. The stabilization of death rates, during the most recent time period may be due, in part, to changes in the classification and coding of causes of death.   Compared to the rates in 1990, the cancer death rate in 2000 was 10.7% lower in men and 4.2% lower in women.
  • Most of the increase in cancer death rates for men prior to 1990 was attributable to lung cancer. However, since 1990, the age-adjusted lung cancer death rate in men has been decreasing. Stomach cancer mortality has decreased considerably since 1930. Death rates from prostate and colorectal cancers have also been declining.
  • Currently, the lung cancer death rate in women is about two-and-a-half times what it was 25 years ago, and lung cancer is the most common cause of cancer death. In comparison, breast cancer death rates were virtually unchanged between 1930 and 1990, and have since decreased. The death rates for stomach and uterine cancers have decreased steadily since 1930; colorectal cancer death rates have been decreasing for over 50 years.
  • Now we will turn our attention to the number of new cancers anticipated in the US this year. It is estimated that 1.37 million new cases of cancer will be diagnosed in 2004. Cancers of the prostate and breast will be the most frequently diagnosed cancers in men and women, respectively, followed by lung and colorectal cancers both in men and in women.
  • Prostate cancer incidence rates increased sharply from 1988 to 1992, after increasing steadily from 1975 to 1988. The short-lived surge in prostate cancer incidence most likely reflects the widespread introduction of the prostate-specific antigen (PSA) screening test in the late 1980s. Lung cancer incidence rates in men have declined in recent years, while rates for cancers of the colon & rectum have stabilized.
  • In women, the breast cancer incidence rate increased rapidly (approximately 4% per year) from 1980 to 1986 and then increased at a slower rate from 1986 through 2000. The apparent decrease in female breast cancer incidence in 2000 is likely due to delay in reporting. Lung cancer incidence rates have continued to increase, although the rate of increase has slowed since the early 1990s. Colorectal cancer incidence rates have leveled off since the mid 1990s. Incidence rates for uterine corpus cancer stabilized from 1998 to 2000, after a slight increase from 1988 to 1998. Ovarian cancer rates have decreased 0.7% per year from 1989 through 2000.
  • The 5-year relative survival rate from cancer is 64% for whites and 53% for African Americans (taking normal life expectancy into consideration). For many sites, survival rates in African Americans are 10% to 25% lower than in whites. This is due, in part, to African Americans being less likely to receive a cancer diagnosis at an early, localized stage, when treatment can improve chances of survival. Additional factors that contribute to the survival differential include unequal access to medical care and a higher prevalence of coexisting medical conditions.
  • Conferencia De Cáncer De Seno Al PúBlico

    1. 1. Qué es el Cáncer, Cuáles son las Estadísticas en Puerto Rico & Cómo podemos prevenir,detectar y manejar el Cáncer de Seno? Raúl H. Morales-Borges, M.D . Instituto de Hematologia & Oncologia Ashford
    2. 2. LA VIDA Y LA ESPERANZA SON MUY BONITAS Y NO PODEMOS NEGARLA. RHMB 2005
    3. 3. Prevención es lo mejor para gozar de una vida saludable. RHMB 2005
    4. 4. Cáncer <ul><li>Cáncer = Cangrejo </li></ul><ul><li>Neoplasma = Crecimiento Nuevo </li></ul><ul><li>Oncos = Tumor </li></ul>
    5. 5. Características de Tumor Benigno <ul><li>Crecimiento lento </li></ul><ul><li>No invasión a otros tejidos </li></ul><ul><li>No metástasis </li></ul>
    6. 6. Características de Tumor Maligno <ul><li>Proliferación de células neoplásticas </li></ul><ul><li>Estroma de soporte </li></ul><ul><li>Neovascularización (vasos sanguíneo nuevos) </li></ul><ul><li>Invasión y Metástasis </li></ul>
    7. 7. <ul><li>Caminas por el bosque y notas que hay árboles diferentes pero dentro de la misma clase; a caso todos somos iguales ? </li></ul>Raul H. Morales-Borges 2005
    8. 8. Grado de Tumores <ul><li>Grado I – Bien diferenciados </li></ul><ul><li>Grado II – Moderadamente diferenciados </li></ul><ul><li>Grado III – Pobremente diferenciados </li></ul><ul><li>Grado IV - Anaplásticos </li></ul>
    9. 9. Estadíos de Tumores malignos <ul><li>Depende del tamaño del tumor, nodulos linfáticos y metastasis </li></ul><ul><li>Estadio I – pequeño </li></ul><ul><li>Estadio II – algo más grande, algunos nodulos </li></ul><ul><li>Estadio III – invasión de estructuras vecinas, más nodulos </li></ul><ul><li>Estadio IV – metástasis </li></ul>
    10. 10. Qué es la Oncología ? <ul><li>Es la rama de la medicina que estudia y trata el cáncer. </li></ul><ul><li>El Oncólogo estudia un bachillerato con premédica (3-4 años), medicina (4 años) y luego hace residencia en medicina interna (3 años) seguido por sub-especialidad en hematología y oncología (3-4 años). </li></ul>
    11. 11. Estadísticas <ul><li>El cáncer es un problema grande de salud publica en los Estados Unidos, Puerto Rico y el mundo entero. </li></ul><ul><li>Es la segunda causa de muerte en USA. Es el responsible de uno de cuatro muertes. </li></ul><ul><li>El cáncer de pulmón es el 2do en lugar tanto en varones com en mujeres en cuanto a incidencia, pero ha disminuído por un 3.3% en los varones y ha aumentado por un 22% en las mujeres. </li></ul><ul><li>El cáncer de seno es la segunda causa de muerte, pero se ha demostrado una disminución en la incidencia y en la mortalidad desde el año 2001. </li></ul>
    12. 12. Muertes por Cáncer PR 2002 Hombres 2,667 Mujeres 1,948 Próstata 21% Pulmón 14% Colorectal 12% Estómago 6% Hígado 6% Esófago 5% Páncreas 4% Linfóma 3% Leucemia 3% Laringe 2% Otras Localizaciones 24% 20% Mama 13% Colorectal 10% Pulmón 7% Estómago 5% Hígado 4% Páncreas 4% Ovario 4% Linfóma 3% Cervix 3% Cuerpo útero, NOS 27% Otras Localizaciones
    13. 13. Tasa de Muerte por Cancer*, Todas las localizaciones, Puerto Rico 1990-2002 Hombres Ambos sexos Tasa por 100,000 Mujeres *Tasas ajustadas por edad a la población Estándar Millón de PR año 2000. Fuente: Registro Central de Cáncer de PR, 2004
    14. 14. Tasa de Mortalidad por Cáncer*, en Hombres, Puerto Rico,1990-2002 Tasa por 100,000
    15. 15. Tasa de Mortalidad por Cáncer*, en Mujeres, Puerto Rico, 1990-2000 Tasa por 100,000
    16. 16. Casos de Cáncer en Puerto Rico, 2000* *Excluye los tumores de piel de células basales y escamosas y el carcinoma in situ de cuello uterino. Hombres5,156 Mujeres 5,131 Próstata 32% Colorectal 13% Pulmón 7% Vejiga Urinaria 4% Estómago 4% Linfóma 4% Hígado 4% Leucemia 3% Esófago 3% Laringe 3% Otras Localizaciones 24% 35% Mama 14% Colorectal 6% Cuerpo útero 4% Cervix 4% Pulmón 4% Linfóma 3% Tiroides 3% Ovario 3% Estómago 2% Leucemia 22% Otras Localizaciones
    17. 17. Tasas de Incidencia de Cáncer* para Hombres, Puerto Rico, 1990-2000 Próstata Pulmón Colorectal Vejiga Uriraria Estómago Tasa por 100,000 *Tasas ajustadas por edad a la población Estándar Millón de PR año 2000. Fuente: Registro Central de Cáncer de PR, 2004
    18. 18. Tasas de Incidencia de Cáncer* para Mujeres, Puerto Rico, 1990-2000 *Age-adjusted to the 1970 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1973-1998, Division of Cancer Control and Population Sciences, National Cancer Institute, 2001. Tasa por 100,000
    19. 19. Supervivencia relativa de cáncer a 5 años*(%) por localización, Puerto Rico,1987-2002 para ambos sexos <ul><li>Todos las localizaciones 34 </li></ul><ul><li>Seno (mujeres) 54 </li></ul><ul><li>Próstata 65 </li></ul><ul><li>Colorectal 28 </li></ul><ul><li>Cuerpo y útero 49 </li></ul><ul><li>Vejiga urinaria 50 </li></ul><ul><li>Cervix 30 </li></ul><ul><li>Pulmón 5 </li></ul><ul><li>Estómago 8 </li></ul><ul><li>Linfóma 35 </li></ul>Localización * La sobrevivencia relativa es a 5 años. Source: Registro Central de Cáncer de PR 2004 .
    20. 20. Más estadísticas de PR <ul><li>13 pacientes de cáncer mueren diariamente en PR (2003). </li></ul><ul><li>3 % DE LOS PACIENTES DE CANCER PARTICIPAN EN ESTUDIOS CLINICOS. </li></ul>
    21. 21. Cáncer más frequentes en mujeres en EUA <ul><li>Seno (mamas) </li></ul><ul><li>Pulmón </li></ul><ul><li>Colon y recto </li></ul><ul><li>Utero (matriz) </li></ul><ul><li>Ovarios </li></ul><ul><li>Linfoma No Hodgkin </li></ul>
    22. 22. Cáncer más frequentes en varones en EUA <ul><li>Próstata </li></ul><ul><li>Pulmón </li></ul><ul><li>Colon y recto </li></ul><ul><li>Vejiga urinaria </li></ul><ul><li>Melanoma </li></ul><ul><li>Linfoma No Hodgkin </li></ul>
    23. 23. Incidencia de Muertes en EUA <ul><li>Hombres </li></ul><ul><ul><li>Pulmón </li></ul></ul><ul><ul><li>Próstata </li></ul></ul><ul><ul><li>Colon y recto </li></ul></ul><ul><ul><li>Pancreas </li></ul></ul><ul><ul><li>Linfoma </li></ul></ul><ul><ul><li>Leucemia </li></ul></ul><ul><ul><li>Esófago </li></ul></ul><ul><li>Mujeres </li></ul><ul><ul><li>Pulmón </li></ul></ul><ul><ul><li>Seno </li></ul></ul><ul><ul><li>Colon y recto </li></ul></ul><ul><ul><li>Pancreas </li></ul></ul><ul><ul><li>Ovarios </li></ul></ul><ul><ul><li>Linfoma </li></ul></ul><ul><ul><li>Leucemia </li></ul></ul>
    24. 24. Cáncer de seno <ul><li>Casos nuevos USA 213000 y en PR 1500. </li></ul><ul><li>Muertes: 40600 </li></ul><ul><li>Casos nuevos en varones: 1300 </li></ul><ul><li>Muertes en varones: 400 </li></ul><ul><li>Probabilidades de desarrollar: 1 / 8 (PR 1/18) </li></ul>
    25. 25. Cáncer de Seno II <ul><ul><li>Incidencia 110/100,000 </li></ul></ul><ul><ul><li>Mortalidad 27/100,000 </li></ul></ul><ul><ul><li>Primeros casos de cáncer seno: Inglaterra para 1805-1933 </li></ul></ul><ul><ul><li>Pico es despues de los 40’s, pero se han visto desde los 20’s </li></ul></ul>
    26. 26. 2007 Estimated US Cancer Cases* * Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. American Cancer Society, Cancer Facts & Figures 2007 Women 678,060 Breast 26% Lung and bronchus 15% Colon and rectum 11% Uterine corpus 6% Melanoma of skin 4% Non-Hodgkin’s 4% lymphoma Thyroid 4% Ovary 3% Kidney and renal pelvis 3% Leukemia 3% All Other Sites 21%
    27. 27. 2007 Estimated U.S. Cancer Deaths* Women 270,100 Lung & bronchus 26% Breast 15% Colon & rectum 10% Pancreas 6% Ovary 6% Leukemia 4% Non-Hodgkin’s 3% lymphoma Uterine corpus 3% Brain and other 2% nervous system Liver and intrahepatic 2% bile duct
    28. 28. Types of Breast Tumors <ul><li>70% to 80% of all breast cancer is infiltrating </li></ul><ul><li>ductal carcinoma </li></ul><ul><li>Benign (fibrocystic changes) </li></ul><ul><li>Noninvasive – Stage 0 </li></ul><ul><ul><li>ductal carcinoma in situ (DCIS) </li></ul></ul><ul><ul><li>lobular carcinoma in situ (LCIS) </li></ul></ul><ul><li>Invasive – Stage I, II, III and IV </li></ul><ul><ul><li>infiltrating ductal carcinoma (IDC) </li></ul></ul><ul><ul><li>infiltrating lobular carcinoma (ILC) </li></ul></ul><ul><li>Inflammatory </li></ul>Available at: http://www.cancer.gov. Accessed March 19, 2007.
    29. 29. Cáncer de Seno con evidencia de engrosamiento de la piel y cambios inflamatorios
    30. 31. Cáncer de Seno en Hombre en los 1800’s
    31. 33. SIN LUZ SEGUIREMOS EN LAS TIENIEBLAS RHMB 2005 RHMB 2005
    32. 34. Prevención, Diagnóstico y Manejo del Cáncer de Seno
    33. 36. Adapted from American Cancer Society (2006) and Hulka et al. (2001).
    34. 37. Factores de Riesgo Hereditarios <ul><li>Familiar de Primer ó Segundo Grado a nivel maternal ó paternal </li></ul><ul><li>BRCA 1 & BRCA 2 </li></ul><ul><li>Li-Fraumeni Syndrome </li></ul>
    35. 38. Factores relacionados a los Senos <ul><li>Enfermedad Fibroquística del Seno </li></ul><ul><li>Hiperplasia Atípica </li></ul><ul><li>Fibroadenomas, Papillomas, Adenosis </li></ul><ul><li>Carcinoma Ductal ó Lobular In Situ </li></ul><ul><li>Carcinoma del Seno </li></ul>
    36. 40. Hartmann, L. et al. N Engl J Med 2005;353:229-237 BENIGN BREAST DISEASES (FIBROCYSTIC BREAST DISEASE)
    37. 41. Otros factores… <ul><li>Radiación Previa al Pecho </li></ul><ul><li>Implantes de Silicon </li></ul><ul><li>Campos electromagnéticos </li></ul><ul><li>Cigarrillo </li></ul>
    38. 42. Accurate clinical staging for breast cancer has always been considered essential before surgery is undertaken ( Sobin & Wittekind, 2002) . However, i t is important to remember the clinical signs of breast cancer that would invalidate surgical attempts at cure. In these instances, initial referral to a clinical oncologist would be more relevant.
    39. 43. The staging systems currently in use are based on the clinical size and extent of invasion of the primary tumour (T), the clinical absence or presence of palpable axillary lymph nodes and evidence of their local invasion (N), together with the clinical and imaging evidence of distant metastases (M). *For T1–3: 'a' indicates no attachment to underlying muscles; 'b' indicates attachment. Adapted from Sobin & Wittekind (2002).
    40. 44. The TNM classificatio has been subdivided into four broad categories by the Union Internationale Contre Cancer. *Many expert groups include T2 tumors in stage I. Adapted from Sobin & Wittekind (2002).
    41. 45. Conocimiento de Receptores Hormonales
    42. 46. cAMP, cyclic AMP; E 2 , oestrogen; 4-OH-E 2 , 4-hydroxyestradiol; ER, oestrogen receptor; EGFR, epidermal growth factor receptor; IGF-1, insulin-like growth factor; MAPK, mitogen-actived protein kinase; mRNA, messenger RNA; PI3K, phosphoinositide 3-kinase; mtProteins, mitochrondrial proteins; Shc, Src homology 2 domain-containing protein; pShc, phosphorylated Shc protein; Ras, GTP-binding protein; Raf, serine/threonine kinase; Src, protein tyrosine kinase. Dashed line arrows indicate putative pathways. Reproduced with permission from Yager & Davidson (2006).
    43. 47. Oestrogens cause activation of various protein kinases, such as mitogen-activated protein kinases (MAPK), and increase levels of second messengers, such as cAMP. EGF, epidermal growth factor; IGF-1, insulin-like growth factor 1; PI3K, phosphoinositide 3-kinase; ERK, extracellular signal-activated protein kinase; JNK, c- jun N-terminal kinase. Reproduced with permission from Yager & Davidson (2006).
    44. 48. Growth factor reduction of progesterone receptor (PR) via direct inhibition of PR gene transcription and induction of membrane-initiated oestrogen receptor (ER) signalling. E 2 , oestradiol; ERK1/2, extracellular regulated kinase 1/2; HB-EGF, heparin-binding epidermal growth factor; HER, human epidermal growth factor receptor; IGF-IR, insulin-like growth factor-1 receptor; mTOR, mammalian target of rapamycin; PI3K, phosphatidylinositol 3-kinase; SERM, selective oestrogen receptor modulator; Tam, tamoxifen. Reproduced with permission from Cui et al. (2005).
    45. 49. Binding of epidermal growth factor (EGF) to the human epidermal growth factor receptor (EGFR) activates a cellular pathway, with induction of phosphorylation by intracellular kinases, leading to nuclear signals that increase cell proliferation. Based on Lo et al. (2006).
    46. 50. Epidermal growth factor receptor (EGFR) family members are dysregulated in many human cancers, suggesting a pivotal role in tumorigenesis ( Grünwald & Hidalgo, 2003) .
    47. 51. A tumour's hormone receptor status can be determined by immunohistochemistry. This photomicrograph demonstrates strong positive nuclear staining (brown or black) for oestrogen receptors in an infiltrating ductal carcinoma.` Reproduced with permission from Dietz J et al. Atlas of Cancer.
    48. 52. Tumours that express ER and/or PR are deemed to be endocrine responsive, while those expressing neither receptor are endocrine unresponsive. ER, oestrogen receptor; PR, progesterone receptor; +, positive (Allred score ≥2); –, negative (Allred score <2); ?, unknown. *Calculated from the Nurses' Health Study (2096 incident breast cancer cases during 1,029,414 person-years of follow-up). Data from Colditz et al . (2004).
    49. 53. Endocrine responsiveness is an important prognostic marker in breast cancer. ER, oestrogen receptor. Reproduced with permission from Hess et al. (2003).
    50. 54. All patients were treated with systemic endocrine therapy (tamoxifen in >90%). ER+, oestrogen receptor positive; ER–, oestrogen receptor negative; PR+, progesterone receptor positive; PR–, progesterone receptor negative. Reproduced with permission from Cui et al. (2005).
    51. 55. Many hormones influence breast development and function, including oestrogens, progesterone, androgens, prolactin, and luteinising hormone-releasing hormone (LHRH). FSH, follicle-stimulating hormone; LH, luteinising hormone; ACTH, adrenocorticotrophic hormone. Based on Dickson (2000) & Russo and Lamarque (1984) .
    52. 56. *The relative risk was calculated with the low-risk group as the reference group. †There is no association between the risk of breast cancer and oophorectomy performed at 35 years of age or older. Reproduced with permission from Clemons & Goss ( 2001).
    53. 57. Oestradiol and, to a lesser degree, other steroid hormones (e.g., progesterone) drive breast cell proliferation, which facilitates mutation, enhances fixation of mutations or facilitates expression of genetic errors by loss of heterozygosity by defects in DNA repair. Germline mutations in relevant tumour-suppressor genes accelerate the transformation to the malignant phenotype. Reproduced with permission from Henderson et al . (2000).
    54. 58. *ACI denotes a cross between August and Copenhagen-Irish strains and SENCAR sensitive to carcinogenesis. Reproduced with permission from Yager & Davidson (2006).
    55. 59. Mamografía : Prueba Estandard para Cernimiento y Detección Tempara
    56. 61. Importancia de la Sonomamografía
    57. 62. El Uso del MRI en el Diagnóstico de Cáncer de Seno
    58. 64. Cirugía Conservadora del Seno
    59. 67. Nódulo Sentinela
    60. 68. A variety of reconstructive techniques are available today aimed at minimising the mutilation effect of mastectomy without compromising the oncological clearance (Ahmed et al, 2005).
    61. 69. (A) A schematic representation of the post-operative appearance after transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. (B) A 35-year-old patient after skin-sparing mastectomy and immediate TRAM. Reproduced with permission from Dietz J et al. (2002).
    62. 70. (A) A schematic representation of latissimus dorsi (LD) flap breast reconstruction. (B) A 38-year-old patient after modified radical mastectomy with immediate reconstruction using the LD flap and submuscular saline implant. Reproduced with permission from Dietz J et al. (2002).
    63. 71. Data from Gazet et al . (1991,1996).
    64. 72. Careful attention to histopathology and quality assurance of treatment delivery is essential to ensure APBI is applied appropriately. To this end, both the American Brachytherapy Society ( Arthur et al ., 2002) and the American Society of Breast Surgeons ( ASBS, 2003) have published recommendations for patient selection criteria for accelerated partial breast irradiation (APBI).
    65. 73. The EBCTCG confirmed that polychemotherapy produced substantial and highly significant proportional reductions in relation to the risk of relapse and death from breast cancer. The effects of treatment were described as either proportional or absolute benefits. For women under 50 years at randomisation, the absolute reduction in risk of relapse was 10.4% for node-negative and 15.4% for node-positive disease. The reduction was also significant for mortality (absolute improvements in 10-year survival of 5.7% and 12.4% for node-negative and -positive disease, respectively). CMF, cyclophosphamide, methotrexate and 5-fluorouracil. Reproduced with permission from the EBCTCG (2005).
    66. 74. AC, doxorubicin, cyclophosphamide; FAC, 5-fluorouracil, cyclophosphamide, doxorubicin; FEC, 5-fluorouracil, cyclophosphamide, epirubicin; HR, hazard ratio; OS, overall survival; T, docetaxel; TAC, docetaxel, doxorubicin, cyclophosphamide; TC, docetaxol, cyclophosphamide. Data from Nabholtz et al . (2002), Jones et al . (2003), Roche et al . (2004), and Bear et al . (2003).
    67. 75. AC, doxorubicin, cyclophosphamide; HR, hazard ratio; OS, overall survival; T, paclitaxel. Data from Henderson et al . (2003) and Mamounas et al . (2003).
    68. 76. Following the success of trastuzumab in metastatic breast cancer, four large international multicentre trials were designed to test the efficacy of trastuzumab as adjuvant treatment either with or following chemotherapy. *Group B from N9831 and Group A from HERA were excluded from the analysis. AC, doxorubicin, cyclophosphamide; LN, lymph node. Data from Romond et al . (2005), Piccart-Gebhart et al . (2005), and Slamon et al . (2005).
    69. 77. Adapted from Piccart et al . (2005). There are international consensus guidelines based on clinicopathological features and outcomes, which are regularly updated to help inform local guidelines and individual clinicians. The 2005 St Gallen guidelines have defined low-, intermediate- and high-risk categories.
    70. 78. The 2005 St Gallen guidelines recommend adjuvant treatment according to risk and endocrine responsiveness. *Depending on clinician and patient discussion. ET, endocrine therapy; CT, chemotherapy. Adapted from Piccart et al . (2005).
    71. 79. AC, doxorubicin, cyclophosphamide; CAF, cyclophosphamide, doxorubicin, 5-fluorouracil; CEF, cyclophosphamide, epirubicin, 5-fluorouracil; CMF, cyclophosphamide, methotrexate, 5-fluorouracil; CT, chemotherapy; FEC, 5-fluorouracil, cyclophosphamide, epirubicin; TAC, docetaxel, doxorubicin, cyclophosphamide. Adapted from Piccart et al . (2005).
    72. 82. Gracias …

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