Ca Breast ppt and management of malignancy.pptx

Carcinoma

1. Ca breast risk factors Moderator - Dr Abhik Chatterjee Dr pawanjeet Kumar Presenter - Romesh

2. Hormonal risk factors Increased exposure to estrogen is associated with an increased risk for developing breast cancer, whereas reducing exposure is thought to be protective. Increased number of menstrual cycles, early menarche nulliparity, late menopause, factors that decrease the total number of menstrual cycles are protective. Moderate levels of exercise and a longer lactation period older age at first live birth is associated with an increased risk of breast cancer. obesity (conversion of androstenedione to estrone by adipose tissue)

3. Non hormonal risk factors Radiation ( hodgkins lymphoma mantle radiation therapy 75 X risk) World war II Alcohol High fat

4. Risk assessment models At birth 12 % lifetime risk in USA Age increases lifetime risk decreases 30 yr 11 % 70 yr 7 %

5. Gail model Variable (relative risk) Age at menarche (years) > 14 (1.00) 12–13 (1.10) < 12 (1.21) Number of biopsy specimens/history of benign breast disease, age < 50 y 0 (1.00) 1 (1.70) > 2 (2.88) Number of biopsy specimens/history of benign breast disease, age > 50 y 0 (1.02) 1 (1.27) > 2 (1.62) Age at first live birth (years) < 20 y Number of first-degree relatives with history of breast cancer 0 (1.00) 1 (2.61) > 2 (6.80) 20–24 y Number of first-degree relatives with history of breast cancer 0 (1.24) 1 (2.68) > 2 (5.78) 25–29 y Number of first-degree relatives with history of breast cancer 0 (1.55) 1 (2.76) > 2 (4.91) > 30 y Number of first-degree relatives with history of breast cancer 0 (1.93) 1 (2.83) > 2 (4.17)

6. Revised gail model includes body weight and mammographic density excludes age at menarche Claus model Claus model incorporates more information about family history but excludes other risk factors The BRCAPRO model is a Mendelian model that calculates the probability that an individual is a carrier of a mutation in one of the breast cancer susceptibility genes based on their family history of breast and ovarian cancer Claus and gail model does not include mutation in BRCA 1 and 2

7. Tyrer cuzick model Tyrer-Cuzick model attempts to utilize both family history information and individual risk information personal risk factors, age at menarche Parity age at first live birth age at menopause history of atypical hyperplasia or LCIS height and body mass index

8. Risk management when to use postmenopausal hormone replacement therapy what age to begin mammography screening or incorporate magnetic resonance imaging (MRI) screening, When to use tamoxifen to prevent breast cancer, when to perform prophylactic mastectomy to prevent breast cancer

9. Post menopausal hormone replacement NO ROLE Women health initiative by NIH > 4 years increase risk The Collaborative Group on Hormonal Factors in Breast Cancer increased risk of breast cancer with ever use of estrogen replacement therapy. Chebowski Million women study

10. Screening USPSTF ACS NCCN United kingdom panel

11. United kingdom panel The expert panel estimated that an invitation to breast screening delivers about a 20% reduction in breast cancer mortality. 11% of the cancers diagnosed in their lifetime constitute over-diagnosis. The use of screening mammography in women <50 years of age is more controversial for several reasons breast density is greater and screening mammography is less likely to detect early breast cancer (i.e., reduced sensitivity) screening mammography results in more false-positive test findings (i.e., reduced specificity), which results in unnecessary biopsy specimens younger women are less likely to have breast cancer (i.e., lower incidence),

12. Chemoprevention Tamoxifen NSABP P-01 The Royal Marsden Hospital Tamoxifen Chemoprevention Trial the Italian Tamoxifen Prevention Trial International Breast Cancer Intervention Study I (IBIS-I) Tamoxifen vs raloxifene P-2 trial, known as the STAR trial Aromatase inhibitors MAP.3 trial IBIS II trial

13. NSABP 01 TRIAL 5-year Gail relative risk of breast cancer of 1.66% or higher or LCIS to receive tamoxifen or placebo. follow-up period of 4 years, the incidence of breast cancer was reduced by 49% in the group receiving tamoxifen. The decrease was evident only in ER-positive breast cancers with no significant change in ER-negative tumors * ALL tamoxifen trials showed with tamoxifen there is increased risk of endometrial cancer, thromboembolic events, cataract formation, and vasomotor disturbances in individuals receiving tamoxifen.

14. Tamoxifen current recommendations women who have a Gail relative risk of 1.66% or higher, who are aged 35 to 59, women over the age of 60 women with a diagnosis of LCIS or atypical ductal or lobular hyperplasia

15. NSABP P2 TRIAL (STAR trial) two agents were nearly identical in their ability to reduce breast cancer risk, but raloxifene was associated with a more favorable adverse event profile. An updated analysis revealed that raloxifene maintained 76% of the efficacy of tamoxifen in prevention of invasive breast cancer with a more favorable side effect profile. The risk of developing endometrial cancer was significantly higher with tamoxifen use at longer follow-up. Although tamoxifen has been shown to reduce the incidence of LCIS and DCIS, raloxifene did not have an effect on the frequency of these diagnoses

16. Aromatse inhibitors MAP.3 trial exemestane was shown to reduce invasive breast cancer incidence by 65%. Side effect profiles demonstrated more grade 2 or higher arthritis and hot flashes in patients taking exemestane. IBIS II trial Non steroidal aromatase inhibitor anastrazole Decrease incidence by 50 % No effect on cognitive fun ction

17. Risk reduction surgery women at high risk for breast cancer prophylactic mastectomy reduced their risk by >90% For BRCA mutation Estimated lifetime risk 40 % prophylactic mastectomy added almost 3 years of life, estimated lifetime risk of 85%, prophylactic mastectomy added >5 years of life bilateral prophylactic or risk-reducing mastectomy have reported dramatic reductions in breast cancer incidence among those without known BRCA mutations, there is little data to support a survival benefit