Breast cancer

Presented by:-
Jaspreet Kaur Sodhi
Associate Professor
Institute of Nursing Education
GTBS© Hospital,Ludhiana
DIAGNOSTDIAGNOST
IC TESTSIC TESTS
ININ
BREASTBREAST
CANCERCANCER

EARly DETECTIONS
REDuCES
THE RISk Of DyING
fROm BREAST
CANCER.

American Cancer Society
Guideline for Breast Cancer
Screening, 2015
• 1. Women with an average risk of breast cancer
should undergo regular screening mammography
starting at age 45 years (Strong
Recommendation).
• Women who are age 45 to 54 should be screened
annually (Qualified Recommendation).
• Women who are age 55 and older should
transition to biennial screening or have the
opportunity to continue screening annually
(Qualified Recommendation).
• Women should have the opportunity to begin
annual screening between the ages of 40 and 44
(Qualified Recommendation).

American Cancer Society
Guideline for Breast Cancer
Screening, 2015
• 2. Women should continue screening
mammography as long as their overall health
is good and they have a life expectancy of 10
years or more (Qualified Recommendation).
• 3. The Society does not recommend clinical
breast examination for breast cancer
screening among average-risk women at any
age (Qualified Recommendation).

Average Risk of Breast
Cancer
•Women without a personal history
of breast cancer.
•A suspected or confirmed genetic
mutations e.g. BRCA
•History of previous radiotherapy to
chest at a young age.

Family genetic factors are the
main criteria defining the
screening group at “high risk”
for breast cancer
• Women with a BRCA1 or BRCA2 mutation;
women who have a first-degree relative with
a BRCA mutation; and women with a 20 - 25%
or greater risk of breast cancer based on risk
assessment tools, which include family
history.
• The recommendations suggest starting
screening at age 30 or earlier but not under
age 25.

The recommendations suggest
specific technologies for each of
the three risk groups.
•Digital or film mammography is
specified for average-risk women.
•Digital supplemented by ultrasound in
intermediate-risk women.
•Digital supplemented by MRI in high-

DIAGNOSTIC STUDIES
FOR BREAST CANCER
PATIENTS
CANCER
STAGES
0 1 II III IV
History And Physical Examination + + + + +
Complete CBC, Platelet count + + + +
Liver Function Test + + + +
Chest Radiograph + + + +
Bilateral Mammography + + + + +
Hormone Receptor status + + + +
HER-2/nue + + + +

The American Cancer Society recommends :
• women over 20 should do a monthly breast
self exam
• women in their 20's and 30's should have a
clinical breast exam every 3 years
• women over 40 should have a clinical
breast exam yearly
American Cancer Society. Detailed Guide: Breast Cancer. 2014. Accessed at
www.cancer.org/Cancer/BreastCancer/DetailedGuide/index

American Cancer Society,
• No longer recommends that all women
perform monthly breast self
examination(BSE).
• But, All Women should become familiar
with both the appearance and feel of
their breast and report any changes
promptly to their physician.
American Cancer Society, Breast Cancer Facts & Figures
2015-2016.Atlanta: American Cancer Society ,Inc.2015

Breast Self Examination
• Opportunity for woman to
become familiar with her
breasts.
• Monthly exam of the
breasts and underarm area.
• May discover any changes
early.
• Begin at age 20, continue
monthly.

When to do BSE?
• Menstruating women- 5 to 7 days
after the beginning of their period.
• Menopausal women - same date
each month.
• Pregnant women – same date each
month.
• Takes about 20 minutes.
• Perform BSE at least once a month.
• Examine all breast tissue.

•Stand in front of a
mirror and look at
each breast
separately.
• Note the size, shape,
colour, contour and
direction of your
breasts and nipples.

Raise your
arms over
your head
and look at
your breasts,
as you turn
slowly from
side to side.

Press your
hands on
your hips and
push your
shoulders
forward. Look
at each breast
separately.

Stand in
front of a
mirror and
start BSE
just below
the collar
bone.

•Use the 3 middle
fingertips of your left
hand for the right breast.
•Apply firm pressure and
make small circles as
you go back or forth in a
pattern covering all the
breast area including the
nipple.
•Extend the examination
to the breast tissue in
the underarm.
•Change your hand and
repeat BSE on the
opposite breast.

•Lie down and raise one arm
above your head.
•Examine your breasts as before,
omitting the underarm.
•Change your arm and repeat BSE
on the opposite breast.

Month .......................
Record:
normal ridges,
lumpy areas, freckles
or moles.
Remember, what you
are looking for are
unusual changes
from your normal.
Record your observations

CLINICAL BREAST
EXAMINATION (CBE)
• The American Cancer Society no longer
recommends CBE for average risk
asymptomatic women based on lack of clear
benefits for CBE.
• The society encourages clinicians to use this
time to counsel women on the importance of
being alert to breast changes and the potential
benefits, harms and limitations of screening
mammography.American Cancer Society, Breast Cancer Facts & Figures
2015-2016.Atlanta: American Cancer Society ,Inc.2015

Defining the Cancer: Radiology
• Radiologic imaging can help determine
the location and spread of the cancer
– Local extent
– Regional lymph nodes
– Distant spread (metastases)

Mammography Technique
Mammography can be
viewed in 2 axis:-
• Cranio-caudal(CC)
• Medio-Lateral

Mammography imaging
compressed breast

a- The breast are almost
entirely fatty. Mammography is
highly sensitive in this setting.
b- There are scattered areas of
fibro-glandular density. The
term density describes the
degree of x-ray attenuation of
breast tissue but not discrete
mammographic findings.
c- The breasts are
heterogeneously dense, which
may obscure small masses.
Some areas in the breasts are
sufficiently dense to obscure
small masses.
d - The breasts are extremely
dense, which lowers the
sensitivity of mammography.
a- The breast are almost
entirely fatty. Mammography
is highly sensitive in this
setting.
b-There are scattered areas of
fibro-glandular density. The
term density describes the
degree of x-ray attenuation of
breast tissue but not discrete
mammographic findings.
c-The breasts are
heterogeneously dense, which
may obscure small masses.
Some areas in the breasts are
sufficiently dense to obscure
small masses.
d-The breasts are extremely
dense, which lowers the
sensitivity of mammography.

•The density of a mass is related to the expected
attenuation of an equal volume of fibro-glandular
tissue.
•High density is associated with malignancy.
•It is extremely rare for breast cancer to be low
density.

BI-RADS
BReAst IMAGInG
RePORtInG And
dAtA sYsteM

Mammography Sensitivity in
Younger Women
Screening mammograms
miss up to 25% of
breast cancers in
women in their 40s,
compared to 10% of
cancers for older
women

After the initial breast
screening,
a follow up
or
Diagnostic Mammographic
is often recommended
when the
BI-RADS category was 3 or
higher.

Digital Mammography
• In digital mammography, the film used to record the
mammogram is replaced by a sensitive digital
detector. The detector provides
• An electrical signal that is digitized, stored in a
computer and displayed on a monitor.
• Unlike film, where the image characteristics are
fixed, in digital mammography, the displayed image
can be adjusted during viewing to enhance visibility
of anatomical information.
• Digital mammography was developed with the
intention of improving performance of mammography
in dense breasts.

Film Digital
Normal film mammography system, Digital mammography system. The
difference is apparent.

Advantages of Mammography
• Early detection of breast cancer by
mammography leads to greater range of
treatment options, including:
less-extensive surgery (eg: breast-conserving
surgery like lumpectomy versus mastectomy)
Use of chemotherapy with fewer side effects

Limitations of Mammography
• Not all the breast cancer will be detected by
mammogram and some breast cancers that are
screen-detected still have poor prognosis.
• False Positive testing.

Radiation exposure
• Many people are concerned about
radiation exposure, the dose required for
a mammogram is very small and the risk
of harm is minimal.

ULtRAsOUn
d• It is particularly useful for investigating
mass lesions and distinguishing
whether they are cystic, solid or
suspicious of malignancy
• However, ultrasound has limited value
in the fatty breast due to lack of
contrast

ULtRAsOUnd
• Unlike MRI, breast ultrasound does not require
the injection of a contrast agent.
• Ultrasound is well tolerated by patients and
does not expose them to ionizing radiation.
• As well, ultrasound is a reasonable alternative
to MRI for women who would otherwise be
eligible for MRI examination, but who either
cannot or are not willing to have an MRI
examination..

Breast MRIBreast MRI
• It uses magnetic fields instead of x-rays to produce
detailed ,cross sectional images of the body.
• Contrast media is injected into a vein in the arm .
• Important new tool for imaging the breast
• High sensitivity.
MRI should supplement ,but not replace
,Mammographic screening.

Principle behind Breast MRI
• As breast cancers grow, they ensure their
blood supply by sending out signals that
recruit the development of new blood
vessels, a process referred to as tumour
angiogenesis.
• These vessels are poorly formed and are
leaky. If an intravenous injection of a
chelated Gd contrast agent is performed, the
agent that leaks from these vessels will pool
in the extra-vascular space and then wash
out.

• Breast MRI produces three-dimensional
images that allow the pattern of leakage
and washout to be monitored.
• The amount of uptake of the contrast agent,
the shape of the enhancing areas and the
kinetics of uptake provide information that
allows very high sensitivity in detecting
breast cancers and distinguishing them
from non-cancerous structures in the
breast.

Advantages of
MRI
• There is no ionizing
radiation, no breast
compression, it’s not
affected by breast
density and it
provides greater than
90% sensitivity.
• MRI is also useful to
guide biopsies and to
show the response of
cancers to neo-
adjuvant
chemotherapy.
Disadvantages of
MRI
• cost of the equipment
• Need for an
intravenous injection
of a contrast medium
and the longer time
required for imaging.

Breast Computed Tomography
imaging a “pendant” breast

Triple Diagnosis
It refers to the concurrent
use of Physical Examination,
Mammography, and skilled
FNAC for diagnosing
palpable breast lumps.

FNAC
If a lump is detected on clinical
examination, but if not picked up by
mammogram or a USG , the lump has
to be further probed and ideal test is
FINE NEEDLE
ASPIRATION
CYTOLOGY.

The National Cancer Institute
recommendation for the diagnosis
of breast aspiration cytology:

Advantages of FNAC
• Well tolerated
outpatient procedure
performed by
palpation or under
ultrasound.
Disadvantages of
FNAC
• Low yield of cells
without normal
surrounding structure.
• Need experienced
cytopathologist.

Breast Cancer Diagnosis
• Any breast change or lump
needs to be evaluated.
• Breast cancer needs to be
diagnosed by biopsy
– Fine needle aspiration
– Core needle biopsy
– Surgical biopsy

Ultrasound-Guided Breast
Biopsy
• Doctors use ultrasound to
guide the needle during the
biopsy.
•This method is used when
lumps are hard to feel on a
breast exam or see on a
mammogram.

Stereotactic core needle
biopsy localization.
•A three-dimensional (3-D) x-ray
guides a biopsy needle to a lump or
other change that cannot be felt on a
breast exam.
•With one type of equipment, patient
lie face down on an exam table with a
hole in it.
• The hole allows patient’s breast to
hang below the table, where the x-ray
machine and needle are.
• Or, special equipment can be
attached to a standard mammogram
machine to x-ray your breast from two

Breast Biopsy
A core needle biopsy of the area is recommendedA core needle biopsy of the area is recommended
Non-
Surgical
Surgical

Needle Biopsies
• Fine Needle – A thin, hollow needle is used to
remove a sample of tissue. The procedure is quick
and can be done in a doctor’s office.
• Core Needle – A larger needle is inserted through a
small incision in the skin, and a small core of tissue
is removed. This type of needle biopsy is done
with the assistance of mammography or ultrasound
imaging using stereotactic techniques with the aid
of the computer, which calculates the precise
location of the lump.

CORE NEEDLE BIOPSY
• A large –bore needle is placed into the
area of suspicion and a core of tissue is
removed.
• Usually several core biopsies are taken
of the area to ensure adequate sampling
of the abnormality .
• This may be done with palpation, under
stereotactic mammography ,or
ultrasound guidance.

Advantages of Core
Needle Biopsy
• High yield of tissue so
less chance of false
readings.
• Tissue is removed with
normal structure and
architecture intact,
which enables more
accurate interpretation.
Disadvantages of
Core Needle Biopsy
• Greater risk of bleeding,
bruising ,or infection.
• Slightly more
uncomfortable

Incisional Biopsy
• A surgical procedure where only a
small amount of the abnormality is
removed through an open incision.
• Generally reserved for lumps that are
larger
• Performed under local anesthesia in a
hospital or outpatient clinic

Advantages of
Incisional
Biopsy.
• High yield of tissue
makes diagnosis
easier.
• Does not remove
large amounts of
tissue for benign
lesions.
Disadvantages of
MRI
• Does not remove all of
the cancer and,
therefore ,another
procedure is
necessary.

Excisional Biopsy
• A surgical procedure that removes the
entire suspected area plus some
surrounding normal tissue.
• Standard procedure for lumps that are
smaller than an inch or so in diameter
• Similar to a lumpectomy
• Performed under local anesthetic or
general anesthesia in a hospital or
outpatient clinic

Advantages of
Excisional Biopsy
• Removes entire lump.
• May be the only surgical
treatment needed.
• Larger samples provide
information for treatment
plan
Disadvantages of
Excisional Biopsy
• May remove large
amounts of tissue that are
benign.
• Removing tissue can
change the look and feel
of the breast.
• Surgical procedure
• Expensive
• Side effects such as
infection or blood
collection under the skin

FNAC
•The sensitivity of FNAC in diagnosis
of breast lesion is 90-95 %.
•Definitive treatment is often based
on cytological diagnosis without
histological confirmation, unless
there is disagreement between
cytology and clinical and/or
mammographic assessment .
Karin Lindholm-Breast. Orell S.R., Sterrett G.F., Whitaker D. — Fine needle
aspiration cytology. 4th edition. Reed Elsevier India Private Limited, New Delhi:
Chapter7, pg.167; 2005.

• FNAC is a valuable method, although moderately less
sensitive than CB.
• CB is the preferred method for preoperative diagnosis
when sampling FNAC provides scarce material and
suspicion of a fibrotic and collagenous lesion such as
lobular carcinoma and radial scar arises.
• FNAC is most accurate when experienced cytologists
are available and when immediate assessment by
professionals is performed for evaluation of material
adequacy, so that additional aspirations can be done
when needed.
Berner A, Davidson B, Sigstad E,Risberg .Fine-needle aspiration cytology vs. core
biopsy in the diagnosis of breast lesions. Diagn Cytopathol. 2003 Dec;29(6):344-8.

Cancer is diagnosed
in 1 of 5
breast biopsies

The Stages of Breast Cancer
Breast Cancer is diagnosed according to stages (stages 0
through IV) under the TNM classification.
Factors used in staging of Breast Cancer:
• Tumor Size
Size of primary tumor
• Nodal status
Indicates presence or absence of cancer cells in lymph
nodes
• Metastasis
Indicates if cancer cells have spread from the affected
breast to other areas of the body (i.e. skin, liver, lungs,
Source: National Cancer Institute

Breast cancer
Spread to lymph nodes
Supraclavicular
Subclavicular
Distal (upper)
axillary
Central (middle)
axillary
Proximal (lower)
axillary
Mediastinal
Internal mammary
Interpectoral
(Rotter’s)

Breast Cancer: Stage I
T1a: TT1a: T ≤≤ 0.5 cm0.5 cm
T1b: 0.5 cm < TT1b: 0.5 cm < T ≤≤ 1 cm1 cm
T1c: 1 cm < TT1c: 1 cm < T ≤≤ 2 cm2 cm
T1 N0 M0T1 N0 M0
TT ≤≤ 2 cm2 cm
T1T1
N0 = no regional lymph node metastasis
M0 = no distant metastasis

Breast Cancer: Stage IIA
T2 N0 M0T2 N0 M0
N1 = metastasis to movable ipsilateral axillary lymph node(s)
2 cm < T2 cm < T << 5 cm5 cm
No evidenceNo evidence
of tumorof tumor
T0T0
T0T0
T1T1
N1 M0N1 M0}
T2T2

Breast Cancer: Stage IIB
T3 N0 M0T3 N0 M0
N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b
T > 5 cmT > 5 cm
T2 N1 M0T2 N1 M0
T3T3

Breast Cancer: Stage IIIA
Metastasis to ipsilateral axillary lymph node(s)
N1 = movable
N2 = fixed to one another or to other structures
T3 N1 M0T3 N1 M0 T0T0
T1T1
T2T2
T3T3
N2 M0N2 M0

Breast Cancer: Stage IIIB
Any T N3 M0Any T N3 M0
N3 = metastasis to ipsilateral internal mammary lymph node(s)
Tumor of any size
with direct extension
to chest wall or skin
T4d = inflammatory
carcinoma
T4 any N M0T4 any N M0
T4T4

Breast Cancer: Stage IV
M1 = distant metastasis (including metastases to cervical, or contralateral
internal mammary lymph nodes)
Any T any N M1

FDG PET scanFDG PET scanBone ScanBone Scan
Staging for Distant Disease:Staging for Distant Disease:
Breast CancerBreast Cancer
Tumor in the breast, butTumor in the breast, but
not elsewherenot elsewhere
Multiple boneMultiple bone
metastasesmetastases
Patient APatient A Patient BPatient B
The most common sites of distant disease in breast cancer are the bones,The most common sites of distant disease in breast cancer are the bones,
liver and lungsliver and lungs

Progress on Biomarkers of
Cancer Diagnosis and
Prognosis

According to Dr. Norman
Boyd,
• Hormone levels vary with the proportion
of dense and non-dense tissue in the
breast.
• Excess estrogen in dense breasts is
believed to accelerate tumour growth.
• Breast density risks apply mostly to
premenopausal women, which is what
makes the 40 - 49 age group, even up to
age 55, so important.

Estrogen receptors(ER)
&
Progesterone receptors(PR)
• Normal breast cells and some breast cancer
cells contains receptors that attaches to
estrogen and progesterone.
• These 2 hormones often fuel the growth of
breast cancer cells.
• Cancer removed during biopsy or surgery is
checked if it has ER or PR.

HORMONE RECEPTOR
POSITIVE
• Breast cancer that have estrogen receptors
are referred to as ER- Positive cancers.
• Breast cancer that have progesterone
receptors are referred to as PR- Positive
cancers.

Tamoxifen
Blocks estrogen from entering into the cell,
blocking estrogen-dependent growth
Nucleus
Tumor cell
Estrogen
biosynthesis
Estrogen
biosynthesis
from muscle & fat
DeVita, et al. Cancer Principles and Practice of Oncology. 6th
ed 2001
Aromatase
Inhibitors Aramatase

Ki-67.
•Ki-67 is a protein in cells that
increases as they prepare to divide
into new cells.
• A staining process can measure the
percentage of tumor cells that are
positive for Ki-67.
• The more positive cells there are,
the more quickly they are dividing
and forming new cells.

What is a biomarker?
Biomarkers are anatomical,
physiological, biochemical or
molecular parameters associated
with the presence and severity of
specific disease states detectable
and measurable by a variety of
methods including physical
examination, laboratory assays and
medical imaging.

Potential uses for
Biomarkers in Oncology

Molecular biomarkers• Gene expression
 microarray
 quantitative reverse transcription-polymerase chain
reaction (RT- PCR)
• Gene amplification
 (FISH/CISH)
• Gene sequence
 DNA sequencing
• Protein expression
 Immunohistochemistry (IHC)
 Enzyme-linked immunosorbent assay (ELISA)
IHC, FISH and ELISA are widely established in clinical
pathology laboratories

HER2 (Human Epidermal Growth
Factor 2)Testing In Breast Cancer

HER2 receptors: Proteins made by the HER2 gene
that receive signals that stimulate cells to grow
and multiply.

HER2 POSITIVE
• HER2-positive breast cancer
is a breast cancer that tests
positive for a protein called
human epidermal growth
factor receptor 2 (HER2),
which promotes the growth of
cancer cells.

IHC
(Immuno-HistoChemistry):
• The IHC test shows whether there is too much
HER2-receptor protein in the cancer cells.
• The results of the IHC test can be 0
(negative), 1+ (also negative), 2+ (borderline),
or 3+ (positive; the HER2 protein is
overexpressed).

FISH
Fluorescent in situ hybridization.
• FISH is a technique
that measures gene amplification using fluorescently
labeled DNA (probe).
• FISH is a fast and highly sensitive technique that provides
an objective scoring system.
• The FISH test shows whether there are too many copies
of the HER2 gene in the cancer cells.
• The results of the FISH test can be positive (extra HER2
gene copies— amplified) or negative (normal number of
HER2 gene copies—not amplified).

Luminal A (HR+/HER2-).
• Most (74%) breast cancers express the
estrogen receptor (ER+) and/or the
progesterone receptor (PR+) but not HER2
(HER2-).
• These cancers tend to be slow-growing and
less aggressive than other subtypes.
• Luminal A tumors are associated with the most
favorable prognosis, particularly in the short
term, in part because expression of hormone
receptors is predictive of a favorable response
to hormonal therapy

Triple Negative Breast
Cancer
• Overall, about 12% of breast cancers are triple
negative, so called because they are ER-, PR-,
and HER2-
• They are also more common in premenopausal
women and those with a BRCA1 gene mutation.
• The majority (about 75%) of triple negative
breast cancers fall in to the basal-like subtype.
• Triple negative breast cancers have a poorer
short-term prognosis than other breast cancer
types, in part because there are currently no
targeted therapies for these tumors

Triple Negative Breast Cancer
• Triple Negative Breast Cancer
– Estrogen Receptor (ER) Negative
– Progesterone Receptor (PR) Negative
– HER2 Receptor Negative
• Considered to have a poorer prognosis than many
other types of breast cancer
• Many existing targeted therapies do not have a
place in TN Breast Cancer therapy (e.g. Herceptin,
Tamoxifen)

Luminal B (HR+/HER2+).
• Luminal B breast cancers are ER+
and/or PR+ and are further defined by
being highly positive for Ki67 (indicator
of a large proportion of actively
dividing cells) or HER2.
• About 10% of breast cancers are ER+
and/or PR+ and HER2+.
• Luminal B breast cancers tend to be
higher grade and more aggressive than
luminal A breast cancers.

HER2-enriched (HR-/HER2+).
• About 4% of breast cancers produce excess
HER2 and do not express hormone receptors.
• These cancers tend to grow and spread more
aggressively than other breast cancers and
are associated with poorer short-term
prognosis compared to ER+ breast cancers.
• However, the recent widespread use of
targeted therapies for HER2+ cancers has
reversed much of the adverse prognostic
impact of HER2 overexpression.

PROGNOSIS OF HER2nue
• In about 1 of every 5 breast cancers, the
cancer cells have a gene mutation that
makes an excess of the HER2 protein.
• HER2-positive breast cancers tend to be
more aggressive than other types of
breast cancer.
• They're less likely to be sensitive to
hormone therapy, though many people
with HER2-positive breast cancer can still
benefit from hormone therapy.

• BRCA1: An abnormal gene, known as
BReast CAncer gene 1, associated with a
higher risk of developing breast cancer.
• BRCA2: An abnormal gene, known as
BReast CAncer gene 2, associated with a
higher risk of developing breast cancer.

• ER-negative: A cancer that does not
have estrogen receptors.
• ER-positive: A cancer that has estrogen
receptors

• IHC (ImmunoHistoChemistry) test: A test
used to measure proteins, including the HER2
protein.
• FISH (Fluorescence In Situ Hybridization)
test: A test for multiple genes, including the
HER2 gene.

CanadIan BREaST CanCER FOundaTIOn – OnTaRIO
REgIOn
EaRlIER dETECTIOn and dIagnOSIS OF BREaST CanCER:a
REPORT FROm IT’S aBOuT TImE! a COnSEnSuS COnFEREnCE
amEndEd OCTOBER 13, 2010
amERICan CanCER SOCIETy. dETaIlEd guIdE: BREaST
CanCER. 2014. aCCESSEd aT
www.CanCER.ORg/CanCER/BREaSTCanCER/dETaIlEdguI
dE/IndEx On SEPTEmBER 3, 2015.
amERICan CanCER SOCIETy. BREaST CanCER FaCTS &
FIguRES 2015-2016. aTlanTa: amERICan CanCER
SOCIETy, InC. 2015.

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