(2 ND EDITION)
(2nd Edition)
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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS
KEY MESSAGES
• Breastcanceristhecommonestcancerinallethnicgroupsandinallagegroupsinfemalesfromtheageof15yearsonwards.TheoverallAge-Standardised IncidenceRate(ASR)was39.3per100,000populationsin2006inMalaysia.
• Ofthecasesdiagnosedin2003,33.6%werewomenbetween40and49yearsofage.
• All Chinese women had the highest incidence with an ASR of 46.4 per 100,000population.
• Tripleassessmentwhichconsistsofclinicalassessment,imaging(ultrasoundand/ormammography)andpathology(cytologyand/orhistology)isanestablishedmethodforthediagnosisofbreastcancer.
• TheAmericanJointCommitteeonCancer(AJCC)CancerStagingManual(7thEdition)hasbeenusedforstagingofcancersintheseguidelines.
• Surgery is themainstayof treatment for earlybreast cancerandconsists of eitherbreast conserving surgery (BCS) or mastectomy, and assessment of axillary lymphnode.
• Breastcancerisrecognisedasasystemicconditioneveninearlystageofthedisease,withasignificantriskofdistantmicro-metastases.Asaresult,adjuvantchemotherapyhasanestablishedroleineradicatingthesemicro-metastases,thusimprovingsurvival.
• The diagnosis of breast cancer is undeniably distressing. In addition to the normalreactionstosuchadiagnosis,manywomenexperienceelevatedlevelsofdistressastheillnessprogresses.
• Palliativecareaimstomaximisethequalityoflifeinthetimeremainingforthepatientwithbreastcancer.
This Quick Reference provides key messages and a summary of the main
recommendations in the Clinical Practice Guidelines (CPG) Management
of Breast Cancer (2nd Edition) November 2010.
Detail of the evidence supporting these recommendations can be found in
the above CPG, available on the following websites:
Ministry of Health Malaysia : h t t p : / / w w w . m o h . g o v . m y
Academy of Medicine Malaysia : h t tp : / /www.acadmed.org.my
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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS
STRATIFICATION OF RISK FACTORSLow Risk Moderate Risk High Risk
•Alcoholconsumption •Increasingagefrom40yearsold
•Personalhistoryofinvasivebreastcancer
•Reproductivefactors:o Increasingageatfirstfull
termpregnancy>30yearo Hormonereplacement
therapyo Oralcontraceptivepill
usage
•Reproductivefactors:oEarlymenarche
(<12yearold)oLatemenopause
(>55yearold)oNulliparity
•LobularCarcinomaInSitu(LCIS)andDuctalCarcinomaInSitu(DCIS)
•Obesity •Benignbreastdiseasewithproliferationwithoutatypia
•Benignbreastdiseasewithatypicalhyperplasia
•Densebreast •Ionisingradiationfromtreatmentofbreastcancer,Hodgkin’sdisease,etc.
•CarrierofBRCA1and2geneticmutation
•Significantfamilyhistoryi.e.1stdegreefamilywithbreastcancer
SCREENING
Mammographymaybeperformedbienniallyinwomenfrom50–74yearsofage
Breastcancerscreeningusingmammographyinlow&intermediateriskwomenaged40–49yearsoldshouldnotbeofferedroutinely
Womenaged40–49yearsshouldnotbedeniedmammographyscreeningiftheydesiretodoso
BSEisrecommendedforraisingawarenessamongwomenatriskratherthanasascreeningmethod
CRITERIA FOR EARLY REFERRAL
• Age>40yearsoldwomenpresentingwithabreastlump
• Lump>3cmindiameteratanyage
• Clinicalsignsofmalignancy
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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS
PATHOLOGY REPORTING
Anadequatepathologyreportforbreastcancermusthavethefollowingminimumparameters:
• Location(sideandquadrant),maximumdiameter,multifocality
• Tumourtype(histology)
• Histologicalgrade
• Lymphnodeinvolvementandtotalnumberofnodesexamined
• Resectionmargins
• Lymphovascularinvasion
• Non-neoplasticbreastchanges
• Hormonereceptorstatus[estrogen-receptor/progesteronereceptor(ER/PR)]
• HER-2assessment
CONTRAINDICATIONS OF BREAST CONSERVING SURGERY (BCS)
• Theratioofthesizeofthetumourtothesizeofthebreastandlocationofthetumourwouldnotresultinacceptablecosmesis
• Presenceofmultifocal/multicentricdiseaseclinicallyorradiologically
• Conditionswherelocalradiotherapyiscontraindicated(suchaspreviousradiotherapyatthesite,connectivetissuediseaseandpregnancy)
SENTINEL LYMPH NODE BIOPSY (SLNB)
SLNBshouldnotbecarriedoutinwomenwithclinicallyinvolvednodes.Thesafetyandefficacyoftheprocedureforbreastcancer>3cmormultifocaldiseasehasyettobedemonstratedinrandomisedcontrolledtrials
SLNBmaybeofferedtothefollowing:
• Unifocaltumourof≤3cm
• Clinicallynon-palpableaxillarynodes
SLNBshouldonlybeperformedbysurgeonstrainedandexperiencedinthetechnique
DualtechniquewithisotopeandbluedyeinperformingtheSLNBispreferred
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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS
SYSTEMIC THERAPYAdjuvantchemotherapyshouldbeconsideredinallpatientswithearlybreastcancer
Adjuvant chemotherapy shouldbeoffered toallwomenwithanyof the following risk factorsespeciallyinpre-menopausalwomen:
• Oneormorepositiveaxillarylymphnodes
• ERandPRnegativedisease
• HER23+disease
• Tumoursize>2cm
• Grade3disease
ENDOCRINE THERAPY
TamoxifenshouldbeofferedtoallwomenwithERpositiveinvasiveearlybreastcancer
RADIOTHERAPYAdjuvantradiotherapyshouldbeofferedtothefollowingpost-mastectomypatientswith:
• ≥4lymphnodes
• Positivemargin
Adjuvantradiotherapycanbeofferedtothefollowingpost-mastectomypatientswith:
• 1-3lymphnodes
• Nodenegativediseasewithhigh riskof recurrencewith twoormore risk factorssuchaspresenceof lymphovascular invasion, tumours>2cm,grade3 tumours, close resectionmargin(<2mm)andpremenopausalstatus
• T3andT4tumours
All patients with post-BCS should be offered adjuvant radiotherapy for both invasivebreastcancerandDCIS
PSYCHOLOGY SUPPORTWomendiagnosedwithbreastcancershouldbescreenedforemotionaldistress
Validated self-assessment psychological tests such asHospitalAnxiety andDepressionScale(HADS),administeredbyatrainedpersonnelmaybeusedtoscreenforemotionaldistressatthetimeofdiagnosis
Allpatientswithbreastcancershouldbeassignedtoabreastcarenursewhowillsupportthemthroughoutthediagnosis,treatmentandfollowup
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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS
FOLLOW UP
Regularfollowupshouldbescheduledasfollows:
• threemonthlyforthefirstyear
• thensix-monthlyforfiveyears
• thenanannualreviewthereafter
Annual mammography should be offered to all patients with early breast cancer who hasundergonetreatmenttodetectrecurrenceorcontra-lateralnewbreastcancer
LIFESTYLE MODIFICATIONDiethighinfibreandlowinfattogetherwithphysicalactivityshouldbeadvisedinwomenafterdiagnosisofbreastcancer
FAMILIAL BREAST CANCER
Womenwhose familyhistory isassociatedwithan increased risk fordeleteriousmutations in
BRCA1, BRCA2 orTP53 genes should be referred for genetic counselling and evaluation for
genetic testing. This includes individuals with affected blood relatives with any one of the
followingfamilyhistorypatterns:
• 3ormoreindividualswithbreastorovariancanceratanyage
• 2ormoreindividualswithbreastcancer,1ofwhomwasdiagnosedat≤50yearsold
• 1individualwithbreastcancerdiagnosedat≤40yearsold
• 1individualwithbothbreastandovariancanceratanyage
• 1individualwithbilateralbreastcanceratanyage
• 1individualwithmalebreastcancer
• 2ormoreindividualswithovariancanceratanyage
• Family history of breast cancer in combination with other BRCA-related cancers such as
pancreas,prostateandoesophagealcancers
• FamilyhistoryofearlyonsetbreastcancerincombinationwithotherTP53-relatedcancers
suchassarcomasandmultiplecasesofchildhoodcancers
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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS
ALGORITHM FOR TREATMENT OF OPERABLE BREAST CANCER
OPERABLE BREAST CANCER
Surgery
Breast Conserving Surgery1, axillary surgery Mastectomy Axillary surgery ± Reconstruction
Low risk1 Intermediate/high risk2
Intermediate/high risk2 Low risk
Adjuvant radiotherapy + Hormone therapy
Chemotherapy ± Herceptin Hormone therapy
Chemotherapy ± Herceptin
Adjuvant radiotherapy ± Hormone therapy
Adjuvant radiotherapy3
± Hormone therapy
1If the surgical margin is 2 mm, several factors should be cons idered in determining whether re-excision is required. These includes:
• Age
• Tumour histology (lymphovascular invasion, grade, extensive in-situ component and tumour type such as lobular carcinoma)
• Which margin is approximated by tumour (smaller margins may be acceptable for deep and superficial margins)
• Extent of cancer approaching the margin
pN0 and all of the following criteria:
• size of tumour max 2 cm
• Grade 1
• no lymphovascular invasion
• ER-/PR-positive
• HER2- negative
• age > 35 years old
pN0 and at least 1 further criteria:
• size of tumour > 2 cm
• Grade 2/3
• vessel invasion present
• HER2 over-expression
• age < 35 years old
• or pN+(N1-3) and HER2-negative
• pN+(N1-3) and HER2 over-expression
or
• pN+ (N > 4)
2Risk Stratification
Low risk Intermediate risk High risk
3 Indication for adjuvant radiotherapy
• 4 or more lymph nodes
• Positive margin
• ± 1-3 lymph nodes
• ± Node negative disease with high risk of recurrence with 2 or more risk factors such as
- presence of lymphovascular invasion, tumours greater than 2 cm, grade 3 tumours, close resection margin (< 2 mm) and premenopausal status