Breast Cancer Symposium - 16 Sept 2009

Breast Cancer Symposium For Primary Care Providers – 16 Sept 2009

Presenters: CDR Henry, MC, USN & Anne Forsha, RN

Basics

Value of early detection

90% survival rate (5 yrs) if caught in a localized state

59% survival rate (5 yrs) if spread to regional lymph nodes

Tamoxifen

If taken for 5 yrs, a 49-88% reduction in risk of estrogen receptor-positive tumors

Fisher B, et al. Tamoxifen for prevention of breast cancer: report of the P-1 study. J Natl Cancer Inst 90:1271, 1998

Raloxifene has lower incidence rates for uterine hyperplasia but this can only be taken by post-menopausal women

6 Dangerous Lies About Breast Cancer

You’re too young to have breast cancer

Cancer dosen’t hurt

Cancer presents as pain in 5% of patients

Negative Mammograms rule out breast cancer

False negatives ~20%

~ 20% of breast cancers are ONLY detected by clinical breast exam

No family history means you are safe

80% of breast cancer patients have NO RISK FACTORS (besides gender)

Men can’t get breast cancer

1% of breast cancers are in men

It’s just mastitis

Diagnostic Imaging

Resolution for MRI ~ 5mm & mammogram ~ 1cm

No evidence to suggest difference in care between these two

Hormone Receptors

Estrogen & Progesterone are primary players

~ 80% of breast cancers are + for hormone receptors

This determines treatment, prevention, & prognosis

Clinical Breast Exam

Start with patient seated and observe for change in size, shape, dimpling, erythema, nipple discharge, nipple retraction

Acronym: B.R.E.A.S.T. – Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, Tender breast

Have pt raise arms over head and observe for skin retraction

Have pt supine with ipsilateral arm over her head & palpate with pads of first 3 fingers

Be sure to include entire area from clavicle to inframammary ridge and from the latissimus dorsi to the sternum

Best time for the exam is just after menses before the spike in progesterone mid cycle when breast gets firmer

Should be performed every 3 yrs from age 25 – 39 and annually from age 40 on

Nipple Discharge

Seen with 3% of breast cancers

Green = OK (probably fibrocystic dz)

Watery/Serous = Bad

Bloody/Serosang = Bad

Spontaneous = Bad

Only one duct = Bad

Estrogen

Study with Prempro (conjugated estrogen & progesterone used to treat symptoms of menopause) Jama 289(24):3304, 2003

16,608 women ages 58-79

Prempro vs placebo

Prempro group

26% increase in breast cancer

22% increase in cardiovascular events

24% decrease in hip fractures

37% decrease in colorectal cancer

Hormone replacement therapy risks are far greater than benefits

Risk Assessment

Hereditary susceptibility

BRCA1 gene: 20% - 40% contribution to hereditary breast cancer

BRCA2 gene: 10% - 30% contribution to hereditary breast cancer

Features indicating increased likelihood of BRCA mutation

Multiple cases of early onset breast cancer

Ovarian cancer (with family history of breast or ovarian cancer)

Breast and ovarian cancer in the same woman

Bilateral breast cancer

Ashkenazi Jewish heritage

Male breast cancer

Risk of breast cancer

General population: by age 50 – 2%, by age 80 – 10%

In mutation carriers: by age 50 – 73% by age 80 – 87%

Who should get genetic testing

Pt with breast or ovarian cancer that was diagnosed at a young age or has a strong family history of breast or ovarian cancer

Lifestyle & Risk

Weight – no clear association

Exercise – no clear association

Alcohol – >2 drinks per day is associated with an increased risk of breast cancer

Tobacco – no clear association

Stress – no clear association

Oral Contraceptives – very little risk for women under 40 yrs