Breast Surgery

Tim Davidson Consultant Surgeon Royal Free Hospital

7 December 2007

breast cancer
commonest female cancer disease of ageing, 75% > 50y 90% sporadic, 10% hereditary lung > breast cancer mortality worries: death, sex, fertility

cumulative lifetime risk (by age 85) = 1 in 10 (incidence, not dying) age 30 age 40 age 50 age 60 10y risk 10y risk 10y risk 10y risk = = = = 1 in 250 1 in 77 1 in 43 1 in 38

BC as cause of dying in women

Breast MRI

breast cancer surgery: to conserve the breast ?

60% 40%
peripheral central < 4cm > 4cm unifocal multifocal WLE + axillary MASTECTOMY staging (BREAST + axillary CONSERVATION) staging

unifocal cancer

wide local excision

wide local excision + radiotherapy

multifocal cancer

mastectomy

modified radical mastectomy

FIGURE 15.2

Halsted radical mastectomy

mastectomy and

risk of local recurrence and EORTC trial 10854 age

Months

Breast cancer surgery: axillary node staging

peripheral central <4cm >4cm unifocal multifocal WLE + axillary MASTECTOMY staging + axillary + post-op RT staging

Nottingham Prognostic Index (NPI)

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diagnosed age 28 WLE + axillary clearance completion mastectomy chemo x 8 cycles chest wall / SCF RT endocrine therapy goserelin delayed reconstruction to come nipple reconstruction symmetrisation? fertility issues

screening: NHS BSP

invitations between 50 - 70 not symptomatic clinics mammograms only; recall aim = mortality reduction possible reduction by 25

screening women aged 50 - 69

breast cancer incidence

2 / 1000 pa = 20 / 1000 per decade

breast cancer mortality

6 / 1000 will die in next decade screening reduces it to 4 / 1000 i.e. 0.2% absolute benefit

Breast cancer : UK statistics

Incidence 1988 25,000 2003 40,000 Mortality 1988 16,000 2003 12,000

RR of breast cancer in later life

menstrual/obstetric history
age at menarche <12 first child after 35 nulliparous

RR
1.3 2.5 2.5 >4 5 10 7 10

family history
2 relatives average age <40 1 relative <50, Ashkenazi ancestry BRCA 1 or 2 gene mutation

precursor lesions
LCIS DCIS

RISK GROUPS

STANDARD RISK 97% (RR<2)

BREAST CANCER

MOD RISK 2% (RR 2-3)

HIGH RISK <1% (RR>3)

Very high risk for breast cancer

BRCA1 gene mutation
lifetime risk 85% breast cancer 60% ovarian cancer

BRCA2 gene mutation previous irradiation for Hodgkins

young, bilateral (15% v 3%)

Bilateral mastectomy and latissimus dorsi flap reconstruction

Breast cancer surgery

Paradox of extent of surgery
advanced disease

invasive early breast cancer noninvasive disease (DCIS, LCIS) surgery for risk reduction

ER +ve patients Disease-free Survival

Proportion with first event (%)
25 20 15 10 5 0 0
At risk: A 2618 T 2598
Absolute Difference 1.6% Absolute Difference 2.6% Absolute Difference 2.5% Absolute Difference 3.3%

A T

HR (95% CI) A vs T 0.83 (0.73-0.94)

P value 0.005

1
2540 2516

3 4 Follow-up time (years)

2355 2304 2268 2189

5
2014 1932

6
830 774

2448 2398

Adverse events in favour of AIs

anastrazole (N=3092) Hot Flushes Vaginal bleeding Vaginal discharge Endometrial cancer* Ischaemic Cerebrovascular Event Venous Thromboembolic Events Deep Venous Thromboembolic Events 35.7 (34.3) 5.4 (4.5) 3.5 (2.8) 0.2 (0.1) 2.0 (1.0) 2.8 (2.1) 1.6 (1.0) tamoxifen (N=3094) 40.9 (39.7) 10.2 (8.2) 13.2 (11.4) 0.8 (0.5) 2.8 (2.1) 4.5 (3.5) 2.4 (1.7) P-value

<0.0001 <0.0001 <0.0001 0.016 0.03 0.0004 0.019

Reduction in contralateral cancers with tamoxifen v AIs

Adverse events in favour of tamoxifen

anastrazole (N=3092) Arthralgia Fractures Fractures of Spine Hip Wrist - spine - hip - wrist (Bisphosphonate usage) 35.6 (27.8) 11.0 (5.9) 5.0 (2.3) 1.5 1.2 2.3 9.6 tamoxifen (N=3094) 29.4 (21.3) 7.7 (3.7) 3.9 (1.5) 0.9 1.0 2.0 6.4 P-value

<0.0001 <0.0001 0.004

use of AIs in early breast cancer

adjuvant AI instead of tamoxifen (5 y) adjuvant switch policy after 2 2.5 y

- anastrazole or exemestane extended adjuvant (after 5y) for further 3 y neo-adjuvant AI therapy - letrozole

HERCEPTIN
20% of invasive cancers HER-2 positive tend to be more aggressive, ER-ve tumours Herceptin well established in metastatic role given after completion of chemotherapy 3-weekly IV infusion, 19K / year cardiac function monitoring

HRT and breast cancer

Million Women Study (Lancet 2003)

Increase in risk of breast cancer RR = 2.0 with combined HRT RR = 1.3 with oestrogen-only HRT RR = 1.45 with tibolone no difference with route of administration risk declines after stopping HRT and by 5y reaches same level as for never taken

PREGNANCY AND BREAST CANCER

breast cancer diagnosed during pregnancy - more advanced stage - poorer prognosis - delay in diagnosis / starting treatment - chemotherapy possible after first trimester pregnancy following breast cancer - no worsening of outlook - advise 2-year wait

Breast cancer : UK statistics

Incidence 1988 25,000 2003 40,000 Mortality 1988 16,000 2003 12,000

benign breast problems

surgery less often required day case procedures benign : malignant = 20:1 worried well

cyst aspiration

benign lump

lumpectomy

Peri-ductal mastitis

inverted nipple

accessory nipple