Management of

Breast Disease
Joseph A. Lucci III, M.D.
Department of Obstetrics and Gynecology
Division of Gynecologic Oncology
 Breast Disease
Role of Primary Care Physician

• Reproductive Health
• Diagnosis
• Treatment
• Cancer Screening
Breast Anatomy
COMPONENTS
• Skin
• Fat
• Gland
• Connective Tissue
• Vessels
Breast Anatomy
TOPOGRAPHY

• Body
• Tail
• Nipple Complex
 Breast Anatomy
GLAND

• 10 – 20 Ducts
• Duct Drains Lobe
• Lobe Contains 20 – 40 Lobules
• Lobule Contains 10 – 100 Alveoli
Breast Anatomy
FASCIAL SUPPORT

• Camper’s Fascia
• Pectoral Fascia
• Cooper’s Ligaments
Breast Anatomy
VASCULATURE

• ARTERIAL
– Internal Mammary
– Lateral Thoracic
• LYMPHATICS
– Drainage
– Nodal Levels
 Breast Anatomy
NODAL LEVELS

• Level I – Lateral Pectoralis Minor

• Level II – Deep Pectoralis Minor
• Level III – Medial Pectoralis Minor
Breast Cancer Location
 Components of Appropriate
Screening Program

• Professional Physical Examination

• Breast Self Examination (BSE)
• Mammography
 Breast Exam
SITTING POSITION

• OBSERVE
– Mass Effect
– Arm Position
• PALPATE
– Breast
– Nodes
 Breast Exam
LYING POSITION

• Positioning
• Palpation
• Discharge
 Breast Disease
Nipple Discharge – 432 Patients

• Benign 88%
• Malignant 12%
 Nipple Discharge

1. Galactorrhea
2. Intraductal papilloma
3. Duct ectasia
4. Carcinoma
Screening Recommendations
Professional Breast Exam

Age Physical Exam

20 – 40 yrs Every 3 years

> 40 yrs Annually

Screening Recommendations
Breast Self Exam (BSE)

Recommended monthly for all

women over the age of 20
Breast Disease
IMAGING

• MAMMOGRAPHY
– 2 Views
– Magnification

• ULTRASOUND
Carcinoma

Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc; 1985:91.
Comedo Carcinoma

Dean P. Teaching atlas

of mammography. New
York, New York:
Thieme Inc; 1985:168
 Ductal Carcinoma

Tabar L, Dean P. Teaching atlas of mammography. 2 nd ed. New York, New York:
Thieme Inc. 1985:169
 Breast Cancer
Mammographic Screening
Mortality
Age ACS NCI Reduction

40 – 49 Q 1 yr Q 1-2 yrs 17%

50 – 69 Q 1 yr Q 1 yr 25 – 30%

70+ Q 1 yr Q 1 yr ?
 Absolute Indications
for Breast Biopsy

• Biopsy any suspicious palpable

lesions.

• Biopsy any suspicious area seen on

mammogram, but not palpable
 Breast Mass
Presumed Benign
N e e d le A s p ir a tio n s

N o n b lo o d y flu id , B lo o d y flu id , n o flu id o r in c o m p le te

m a s s d is a p p e a r s d is a p p e a r a n c e o f m a s s

O b s e rv e X 1 m o E x c is io n a l b io p s y

M ass No Cancer B e n ig n
re c u rre n c e re c u rre n c e

B io p s y F o llo w T re a tm e n t F o llo w
P O E P
FIBROCYSTIC CHANGES

• 50 – 80% of all women

• Etiology
• Diagnosis
• Treatment
FIBROCYSTIC CHANGES
Diagnosis

• Palpation
• Mammography
• Ultrasound
• Aspiration
• Biopsy
Fibrosystic Changes
TREATMENT
• OCP’S
• Methylxanthines
• Nicotine
• Vitamin E
• Hormones
• Bromocriptine
 Fibrosystic Changes
CANCER RISK

• Extent of Proliferative Changes

• Variable
Proliferative Breast Disease
CANCER RISK

Hyperplasia 1.9

Atypical Hyperplasia 4.5

AH + FM HX 11

Cysts 1.5

Cysts + FM HX 3.0
Sclerosing Lesions

• Fibrocystic Changes
• Small, Irregular
• Resembles CA
• DX: FNA
• TX: Excision
Sclerosing Duct Hyperplasia

Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:106
 Adenoma

• Age: 20 – 30 yrs
• Groups
– Tubular
– Lactating
• DX: FNA
• TX: Observe, Excision
Fibro-adeno-lipoma

Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:25
Lipoma

Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:21
Fibroadenoma

• Age 20 – 49 yrs
• Firm, Painless
• Bilateral 15 – 25%
• DX: FNA
• TX: Observe, Excise
Fibroadenoma

Tabar L, Dean P.
Teaching atlas of
mammography. 2nd ed.
New York, New York:
Thieme Inc. 1985:200
 Phylloides Tumor

• Age: 30 – 55 yrs
• Slow Growing
• Epithelial and Stromal
• 10% Sarcoma
• DX: FNA
• TX: Excision
 Cystosarcoma Phylloides

Tabar L, Dean P. Teaching atlas of mammography. 2 nd ed. New York, New York:
Thieme Inc. 1985:63
 Intraductal Papilloma

• Age: 45 – 50 yrs
• Bloody Discharge
• Unilateral, small
• TX: Excision
• CA Risk: Rare, Multiple Lesions
 Intraductal Papilomatosis

Tabar L, Dean P. Teaching atlas of mammography. 2 nd ed. New York, New York:
Thieme Inc. 1985:192
 Intraductal Papillomatosis

Tabar L, Dean P. Teaching atlas of mammography. 2 nd ed. New York, New York:
Thieme Inc. 1985:48
 Ductal Ectasia

• Age: Perimenopausal
• Bilateral
• Sticky, Thick, Green Discharge
• DX: Exam
• TX: ABX, Excision
• CA Risk: Rare
 Breast Cancer
US Statistics, 2000

• 182,800 new cases in women

• 40,800 deaths in women
• 1:8 women will develop breast
cancer in lifetime

Greenlee et al, CA Cancer J Clin 2000, 50:7-33

 Cancer Incidence 1998

New Death
Breast 180,300 43,500
Lung 83,300 68,400
Colon 68,900 28,900
Endometrium 36,100 6,300
Ovary 25,400 14,500
Cervix 13,700 4,900

Cancer Facts and Figures – ACS, 1998

 Breast Cancer
Five Year Survival (1989-95)

Localized 97%

Regional 78%

Distant 22%

Overall 86%

Greenlee et al, CA Cancer J Clin 2000, 50:7-33

 Breast Cancer

• Incidence has plateaued since 1987

• Mortality rates have been stable or declining
• 5 year survival for localized disease has improved

1940 78%
1993 93%
1997 97%
Presentation of Breast Cancer
(744 Patients)
Breast Cancer
RISK FACTORS
• Sex
• Parity
• Menses
• Socioeconomic
• Race
• Diet
• Weight
Breast Cancer Risk Assessment
Modified Gail Model
• Age
• Family history of breast cancer
• Age at first live birth, if any
• Number of breast biopsies
• History of atypical hyperplasia
• Age at menarche
• Race
 Breast Cancer
Family History
Relative Risk
of Breast Calculated
Family History Cancer Lifetime Risk
Unilateral

Premenopausal 3.1 21.7%

Postmenopausal 1.5 10.5%

Bilateral 5.4 37.8%

Premenopausal 8.8 61.6%

Postmenopausal 4.0 28.0%

 Breast Cancer
Risk Factors
RR
First Pregnancy (>30 yrs) 1.48
Body mass index (>29.68 kg/m2) 1.48
College graduate 1.36
Alcohol use (>5 g/d) 1.16
Delayed menopause 1.14 (5 yrs)
HRT (current) 1.12 (5 yrs)*

*based on data from Collaborative Group on Hormonal Factors in Breast Cancer. Lancer. 1997; 350-1047.
 Breast Cancer
DECREASED RISK

• Early Pregnancy
• Castration
• Exercise
• Avoid ETOH
 Chemical Structure of
Estradiol and Selected SERMs
 BCPT Design: Schema

Eligible Women at High Risk

(5-yr risk ≥ 1.66% or age over 60)

Randomization
n = 13,388

Tamoxifen Placebo
5 years 5 Years
n = 6681 n = 6707

Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388.

 BCPT Objectives

• Primary End Point

• Incidence of invasive breast cancer
• Secondary End Points
• Breast cancer mortality
• Incidence of cardiovascular events
• Incidence of bone fractures

Fisher et al. J Natl Cancer Inst 1998. 90:1371-1388

BCPT Results: Invasive Breast Cancer

Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388

BCPT Results: Invasive Breast Cancer
Cases by Previous Pathology

*Not statistically significant

Fisher et al. J Natl Cancer Inst 1998;90:1371-1388
 Tamoxifen Chronic Effects:
NSABP P-1
Per 1000 Women/Yr
Placebo Tamoxifen
Hip Fracture .84 .46
Total Fracture 5.28 4.29
Cardiac Ischemia 2.37 2.73
DVT .84 1.34
PE .23 .69
CVA .92 1.45
TIA .96 .73
Cateracts 21.72 24.82
Cateract Surgery 3.00 4.72
Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388.
 Endometrial Cnacer:
NSABP P-1
Number Rate Per 1000/Yr
Event Placebo Tamoxifen Placebo Tamoxifen

Invasive Ca 15 36 .91 2.30

< 49 yrs 8 9 1.09 1.32
> 49 yrs 7 27 .76 3.05
Stage I 14 36
Stage IV 1 0
Deaths 1 0
Ca in situ 3 1 .06 .35

Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388.

 BCPT QOL: Symptoms Reported
at Least Once Over 36 Months
All age Groups %
Risk
Symptom Tamoxifen Placebo Ratio
Vaginal discharge 55 34 1.60

Cold sweats 21 15 1.45

Genital itching 47 38 1.23

Night sweats 67 55 1.22

Hot flashes 78 65 1.19

Day et al. J Clin Oncol 1999. 17(9):2659-2669

 More study

Postmenopausal women
With osteoporosis
(n = 7704)

Palcebo Raloxifene Raloxifene

60 mg/d 120 mg/d

Cummings SR et al. Proc Am Soc Clin Oncol. 1998;17-2a

Raloxifene and Breast Cancer
Prevention Trials
• MORE Trial
– Breast Cancer risk not specifically
addressed at entry
– 70% reduction at 33 months
• 9 trials – 10,575 patients
– Mean follow-up = 40 months
– 67 breast cancer events
– 55% reduction in relative risk
Carcinoma

Tabar L, Dean P.
Teaching atlas of
mammography.
2nd ed. New York,
New York:
Thieme Inc.
1985:95
Breast Cancer
STAGING

• Evaluation
– H&P
– CXR
– Bone Scan
– Labs
• TNM
Breast Cancer
TREATMENT

• Surgery
• Radiation
• Chemotherapy
• Hormones
 Breast Cancer
SURGICAL THERAPY
• In SITU
• Location
• Tumor Size
• Breast Size
• Patient Age
• Patient Preference
• Mammographic Appearance
 Breast Cancer
SURGICAL THERAPY

• Breast Conservation
– Lumpectomy
– Sentinal Node(s)

• Modified Radical Mastectomy

and Papillary Node Disection
 Breast Cancer
PROGNOSTIC FACTORS
• Size
• Nodes
• Stage
• Grade
• Ploidy
• S – Phase
• Necrosis
• HER-2/neu
 Breast Cancer
ADJUVANT THERAPY

• Premenopausal – Chemo
• Postmenopausal – Hormones
Breast Cancer
CHEMOTHERAPY

• Regimens
– CMF
– CAF
– AC
• 6 – 12 Cycles
 Breast Cancer
RADIOTHERAPY
• All Breast Concerving Surgical Therapies
• High Risk Patients
• When
– After Chemo
– Middle of Chemo
 Breast Cancer
HORMONE THERAPY

• Tamoxifen x 5 years
• All Patients
• Ovarian Ablation
Breast Cancer Survival Rate According
to AJCC Stage