These are the slides that accompany the video found on www.aboutcancer.com

1. BREAST CANCER
Robert Miller MD
www.aboutcancer.com

2. • Breast cancer most common cancer in women (29% cases)
• Life time risk of 12.38% (one in eight)
• Median age at diagnosis is 61 but (5% 30s, 18% in 40’s, 25%
50’s)
Age Distribution 5 Year Survival by Stage

3. What You Need to Understand About Breast
Cancer Before Deciding on Treatment

4. What You Need to Know About Breast Cancer Before
Deciding on Treatment
• Understand the basic anatomy (lobules, ducts and lymph nodes)
• Breast imaging studies (mammograms or ultrasound) CT, MRI, PET
• Stage (particularly lymph node status)
• Biopsy or pathology report tell you about the biology (how aggressive) of
the cancer
1. Pectoralis Muscle, 2. Fatty Breast Tissue, 3.
Breast Cancer, 4. Breast Glands (lobules), 5.
Milk Ducts

6. Lymph Nodes
supraclavicular
Internal mammary
axillary
The tail of the
breast may extend
high into the
axilla

7. Imaging

8. Imaging
a case of advanced
cancer… 3 views of the
same tumor in a woman
with a 2.7 cm breast
cancer
Most women are
diagnosed at an early
stage with abnormal
calicifications on their
mammogram

9. Mammograms may often show areas of
calcification, which can be benign or
malignant

10. Mammograms may often show areas of
calcification, these may be malignant. In ductal
carcinoma in situ (DCIS), there is normally no mass
but just an area of calcification

11. Micro-
calcifications
can be very
subtle
Biopsy of this
area showed
8mm DCIS

12. Biopsy = DCIS with focal micro-invasion

13. Larger area of
fat
micro-
calcifications may
have invasive
gland cancer
Path = 2.9 cm
area of high grade
DCIS plus invasive
ductal cancer

15. Breast MRI Scan
In a woman with dense breasts, the mammogram was
normal but the MRI showed the cancer

16. benign
Breast
MRI
Path = 2.2 cm
cancer in
right breast,
left breast
was benign
(False
positive?)

17. Breast MRI
Will show the breast tumor
as well as the lymph nodes
Mastectomy = 6cm lobular cancer with 41 out
of 42 lymph nodes positive for cancer spread

18. Breast MRI Scan
A = Breast
B = axilla
C = internal
mammary nodes

19. CT Scan Anatomy

20. PET Scan Anatomy for Breast Cancer

21. PET - CT Scan Anatomy - Reconstruction

22. Small relapse on the reconstructed right breast, just above the implant

23. PET Scan: previous right mastectomy but
cancer has recurred arising from the rib

24. PET Scans are usually reserved for more
advanced cases of breast cancer

25. PEM (Positron Emission Mammography)

26. Sentinel Node
Technique and Biopsy
Sentinel Node

27. Sentinel Node Technique
nodes
Breast cancer

28. Stage is based on the tumor size
(T1 – T4)
T 0 = DCIS
T1 = 2cm
T2 = > 2 – 5cm
T3 = > 5cm

29. Stage is based on lymph node spread
(N1 – N3)
N0 = no nodes
N1 = 1 -3 nodes
N2 = 4 – 9 nodes
N3 = 10 nodes
or SCV or IMC

30. Odds of Spread to Sentinel Node
The bigger the
tumor the more
likely it has spread
to the lymph nodes
Tumor size in cm
If the biopsy shows
a more aggressive
form of cancer (high
grade cancer) or
cancers cells are
seen in vessels (LV)
then there is a high
chance the cancer
has spread to the
nodes
Grade and LV invasion

31. Breast Cancer Stage

32. So the stage if based on both the tumor size or the lymph
node status, so stage IIB would be T2N1 or T3N0
N0
T3
N1 T2

33. Mortality based on size of cancer and number
of lymph nodes involved
6 + Nodes
3 + Nodes
0 + Nodes
Tumor size in cm

34. Mortality based on cancer grade for node
negative and node positive cancers
2cm tumor
with 3 + nodes
2cm tumor
with 0 + nodes
Cancer Grade

35. Understanding a Pathology
Report
1. Invasive or Not (DCIS, LCIS)
2. Histology: what type of cancer
3. Grade: fast or slow growing
4. Hormone Receptors: is it sensitive to estrogen or progesterone
5. HER2 (human epidermal growth factor receptor 2) a genetic
mutation

36. ductal cells
ductal carcinoma In situ Invasive ductal carcinoma
(DCIS)

37. 20% of breast
cancers in the US
are stage 0 or non-
invasive (ducal
carcinoma in situ
DCIS or lobular
carcinoma in situ
LCIS)

38. Earliest form of cancer
is often DCIS (ductal
carcinoma in situ) then
it progresses to
invasive ductal
carcinoma

39. DCIS – Ductal Carcinoma In Situ

40. Types of Invasive Breast Cancer
Histology Common Aggressive
Invasive Ductal 50 – 75% Average
Invasive Lobular 10 – 15% Average
Medullary 1 – 5% More
Mucinous (colloid) 1 – 5% Less
Papillary (<1%) Less
Tubular (1 – 5% Less

42. Cancer Cell
A genetically altered or mutated
normal cell that results in
uncontrolled growth and spread
If the cell has not mutated too much it almost looks like a normal cell
(and would be called low grade or well differentiated) would
probably still have a normal response to estrogen and be less
aggressive (less likely to spread or grow rapidly)

43. Breast Cancer Grade
Grade Description 5Y Survival
1 (low) Well-differentiated, slow growing 95%
2 (most common) Moderately formed 75%
3 (high) Poorly formed, aggressive 50%

44. Hormone Receptors
Normal breast cells are sensitive to hormones (estrogen and progesterone)
and have chemical receptors that the hormones attach to. About 60 to
70 % of breast cancer cells with still have these receptors.
This is good for two reasons:
1. The cancer cells are less mutated (or dangerous) and the patient's
prognosis (outlook) is better
2. Instead of just chemotherapy the woman may benefit from a hormone
blocking drug like Tamoxifen (if she’s premenopausal) or an aromatase
inhibitor like Femara, Aromasin or Arimidex

45. HER2
(Human Epidermal Growth Factor Receptor Type 2)
About 20 to 30% of the cancers will have the genetic mutation that leads to
abnormal function of the HER2 gene. This is considered a more serious type of
cancer but there are antidote drugs available like Herceptin (trastuzamab) against
these cells

46. HER2
(Human Epidermal Growth Factor Receptor Type 2)

47. Gene expression array methodology
A) RNA from a tumor probes for thousands of genes have been affixed. B) The red
(relative overexpression in tumor) and green (relative underexpression in tumor)
intensities can be analyzed simultaneously. C) Depending on the supervision of the
analysis, tumors can be subtyped (as shown here), or can be analyzed for gene sets
associated with clinical outcome.

48. Genetic Profiles
May show that some women with favorable breast cancer (estrogen + and
node -) may need more than just Tamoxifen / analyze the cancer for the
presence (expression of 21 breast cancer genes)

49. Genetic Profiles
May show that some women with
favorable breast cancer (estrogen
+ and node -) may need more
than just Tamoxifen
27% of women had
a high risk gene
profile and 30.5%
relapsed after
Tamoxifen and they
may have done
better with
chemotherapy

50. MammaPrint is the first and only FDA-cleared IVDMIA breast cancer recurrence assay. The unique 70-
gene signature of MammaPrint provides you with the unprecedented ability to identify which early-stage
breast cancer patients are at risk of distant recurrence following surgery, independent of Estrogen
Receptor status and any prior treatment.
Unlike previous generation genomic tests, MammaPrint interrogates all of the critical molecular
pathways involved in the breast cancer metastatic cascade. It analyzes 70 critical genes that comprise a
definitive gene expression signature and stratifies patients into two distinct groups — low risk or high
risk of distant recurrence. With MammaPrint, there are no intermediate results.
Hormonal therapy alone (e.g. Tamoxifen) may be sufficient to further reduce her risk if your patient is
Low Risk by MammaPrint, when combined with traditional risk factors. Conversely, if she is High Risk
by MammaPrint and has additional risk variables, more aggressive therapy including chemotherapy may
be recommended.

53. BREAST CANCER
Robert Miller MD
www.aboutcancer.com