Breast Cancer

• Normal incidence of breast cancer is 8 - 10%
• Peak incidence of breast cancer is at age 63 years
• Men can also get breast cancer, with an incidence said to be 1 male for every 100 females
• Risk factors for breast cancer include female sex, age, genetics or family history, and BRCA 1 & 2 mutations
• Risk factors for breast cancer

  • Female sex
  • Age
  • Genetics or family history
  • BRCA 1 & 2 mutations
  • Smoking
  • Alcohol
  • Breastfeeding
  • Age at menarche and menopause
  • Hormonal use
• Diagnosis of breast cancer

  Triple assessment consisting of Clinical assessment, Imaging, and Histology
• If a firm increases advertising

  The demand curve shifts right, increasing the equilibrium price and quantity
• Marginal utility is the additional satisfaction gained from the consumption of an additional product, and total utility is the sum of marginal utilities for each unit
• Metastatic screening for breast cancer is done clinically, radiologically, and with blood tests
• Application of TNM staging for breast cancer

  Clinical examination for metastatic disease, CXR for lung metastases, abdominal and pelvic ultrasound for abdominal evaluation, CT scan and PET CT for advanced investigations if needed, blood tests including FBC, LFT, Ca, and tumor markers
• If metastatic disease is found, it must be treated preferentially as surgery or treatment of the primary disease will not improve survival
• If no metastatic disease is found, treatment of the primary lesion is indicated
• Treatment plan for breast cancer

  Evaluation of operability of primary lesion, consideration of neo-adjuvant systemic therapy if inoperable, surgical options of mastectomy or breast conservation followed by radiotherapy, planning 2nd line therapy if needed
• Treatment plan for inoperable cases

  1. Removal followed by radiotherapy

  2. Plan 2nd line therapy or possibly hormonal treatment or radiotherapy
• Surgical options

  Mastectomy or breast conservation
• Breast conservation must always be followed by radiotherapy to decrease the risk of local recurrence
• Reconstruction should be considered after mastectomy and offered to all patients
• The only indication for breast conserving surgery is COSMESIS
• The most important pre-requisite for breast conserving surgery is that the margins must be clear
• Axillary dissection is a staging procedure
• Decisions about systemic therapy and radiotherapy are made based on axillary findings
• If axilla is clinically involved, an axillary dissection is indicated
• If axilla is not involved clinically or radiologically, a sentinel node biopsy is indicated
• Role of radiotherapy


  Part of loco-regional control, used to control microscopic disease, marked tumor bed with metal clips for boost dose
• Radiotherapy is not indicated after mastectomy unless more than 4 involved nodes are found after axillary dissection
• Radiotherapy plays no role in systemic treatment or treatment of metastatic disease except for spinal cord compromise
• Urgent MRI and radiotherapy are needed for vertebral metastases with neurological symptoms to prevent paralysis
• Brain metastases are radiated due to enclosed bony "box" and blood/brain barrier
• Role of Chemo and Hormonal Therapy

  Used to treat systemic disease, prevent systemic recurrences, determined by various factors including tumor behavior, size, lympho-vascular involvement, and nodal status
• Adjuvant therapy should start as soon as possible after surgery, no benefit after 84 days
• Chemotherapy is given as a combination of several agents such as 5-Fluorouracil, Cyclophosphamide, and Adriamycin
• Adriamycin is cardiotoxic, so patients need cardiac monitoring
• Newer regimen for younger patients is a combination of Cyclophosphamide, Adriamycin, and taxane
• Hormonal therapy includes Selective oestrogen receptor modulators for pre-menopausal women and Aromatase-inhibitors for post-menopausal women
• Hormonal therapies are given in tablet form and used daily for 5-10 years