MINISTRY OF SCIENCE AND HIGHER EDUCATION OF THE

RUSSIAN FEDERATION
FEDERAL STATE BUDGETARY EDUCATIONAL INSTITUTION
OF HIGHER EDUCATION
«NATIONAL RESEARCH OGAREV MORDOVIA STATE
UNIVERSITY»
DEPARTMENT OF ONCOLOGY WITH A COURSE OF RADIATION
DIAGNOSTICS AND RADIATION THERAPY

Breast Cancer In INDIA

YOUISUF SK
637
CHECKED BY- MOHAMMED ABDELAZIZ AHMED
 BREAST ANATOMY
•The breasts of an adult woman are milk-producing, tear-shaped glands.
•A layer of fatty tissue surrounds the breast glands and extends
throughout the breast, which gives the breast a soft consistency and
gentle, flowing contour.
•The breast is responsive to a complex interplay of hormones that cause
the breast tissue to develop, enlarge and produce milk.
•Each breast contains 15 to 20 lobes arranged in a circular fashion.
•Each lobe is comprised of many lobules, at the end of which are tiny
bulblike glands, or sacs, where milk is produced in response to hormonal
signals.
•Ducts connect the lobes, lobules, and glands; in nursing mothers, these
ducts deliver milk to openings in the nipple.
•Breast tissue is drained by lymphatic vessels that lead to axillary nodes
(which lie in the axilla) and internal mammary nodes (which lie along
each side of the sternum).
 COOPER’S LIGAMENT

– Fibrous septa running between the superficial

fascia (skin) and the deep fascia (covering muscles of
the chest wall).
 QUADRANTS OF THE BREAST
Quadrants:
– Upper Inner (UI)-(14.2%)
– Upper Outer (UO) -(38.5%)
– Lower Inner (LI)-(5%)
– Lower Outer (LO)-(8.5%)
• Upper Outer Quadrant
– Extends into region of the low axilla (axillary
tail of Spence)
– Greater percentage of breast tissue
– Greater percent of breast caners
 REGIONAL LYMPH NODES:
1Axillary lymphatic plexus 2.Cubital lymph nodes * 3.Superficial axillary
(low axillary)
4. Deep axillary lymph nodes
5. Brachial axillary lymph nodes
6. Interpectoral axillary lymph nodes (Rotter nodes) 7.Paramammary or
intramammary lymph nodes 8.Parasternal lymph nodes (internal mammary
nodes)
• Axillary lymph nodes
• 3 levels
– Based on relationship to
pectoralis minor muscle
• Level I axilla
– Caudal and lateral to
pectoralis minor m.
• Level II axilla
– Beneath pectoralis minor m.
• Level III axilla
– Infraclavicular region
– Cranial and medial to
pectoralis minor m.
 BREAST BLOOD SUPPLY COMES FROM THREE
SOURCES:
• Branches of the axillary artery supply the lateral part of
the breast. These are the superior thoracic,
thoracoacromial, lateral thoracic and subscapular arteries.
• Branches of the internal thoracic artery, supply the
medial part of the breast as the medial mammary arteries.
• Perforating branches of second, third and fourth
intercostal arteries contribute to the supply of the entire
breast. Breast veins follow the mentioned arteries. They
drain into the axillary, internal thoracic and second to
fourth intercostal veins.

Innervation:
Anterior and lateral cutaneous branches of the second to sixth intercostal nerves,Fourth
intercostal nerve (nipple).
 BREAST CANCER
What is breast cancer?
Breast cancer is a cancer that forms in the tissues of the breast – usually in the ducts
(tubes that carry milk to the nipple) or lobules (glands that make milk). It occurs in
both men and women, although male breast cancer is rare.

Overall, the average risk of a woman in the United States developing breast cancer
sometime in her life is about 13%. This means there is a 1 in 8 chance she will
develop breast cancer.

Breast cancer has ranked number one cancer among Indian females with age
adjusted rate as high as 25.8 per 100,000 women and mortality 12.7 per 100,000
women. Data reports from various latest national cancer registries were compared
for incidence, mortality rates.

"West Bengal has five lakhs cancer patients. 70,000 cases of cancer are detected
every year in the state out of which 35,000 die annually due to cancer," medical
director, Netaji Subhas Chandra Bose Cancer Research Institute Ashis
Mukhopadhyay said.
 EPIDEMIOLOGY:
Breast cancer is a significant health concern in India, comprising 14% of cancers in women.
Every four minutes, an Indian woman is diagnosed with breast cancer. In 2018, 1,62,468
new cases and 87,090 deaths were reported. Survival rates are lower in later stages, with
over 50% of women diagnosed at stage 3 or 4. The post-cancer survival rate for Indian
women is 60%, compared to 80% in the U.S. Kerala has the highest cancer rate in India,
followed by Mizoram, Haryana, Delhi, and Karnataka. Breast cancer risk peaks between
ages 50-64. Lack of awareness and poor early screening contribute to the low survival
rates. The incidence of breast cancer is rising, constituting 25-32% of female cancers in
major cities. Early detection is crucial for better outcomes, emphasizing the importance of
awareness, healthy lifestyles, and regular self-examinations.

According to the latest WHO data published in 2020 Breast Cancer Deaths in Russia
reached 23,242 or 1.41% of total deaths. The age adjusted Death Rate is 16.34 per 100,000
of population ranks Russia #99 in the world.

Breast cancer is the most common cancer in women in the WHO Europe region with an
estimated incidence of 576,300 in 2020*. Incidence in the EU-27 in 2020 was estimated to
be 355,500*. 1 in 11 women in the EU-27 will develop breast cancer before the age of 74*.

It is about 30% (or 1 in 3) of all new female cancers each year. The American Cancer
Society's estimates for breast cancer in the United States for 2023 are: About 297,790 new
cases of invasive breast cancer will be diagnosed in women. About 55,720 new cases of
ductal carcinoma in situ (DCIS) will be diagnosed.
Causes And Risk Factors for Breast Cancer
GENETIC AND FAMILIAL FACTORS

• Familial breast cancer

– 10% of patients
– Germline mutations in tumor suppressor genes
• p53, BRCA1, BRCA2
• BRCA1 and BRCA2
– < 1% of the population
– < 7% of breast cancer patients
– Mediate effects of cell response to DNA damage
– BRCA1
• Lifetime risk of breast cancer 65-85%
• Lifetime risk of ovarian cancer 50%
• Increased risk of colon and prostate cancer
– BRCA2
• Lifetime risk of breast cancer 65-85%
• Increased lifetime risk of ovarian cancer, but less than that for BRCA1
• Associated with pancreatic cancer and male breast cancer
 BREAST CANCER PATHOGENESIS:
Breast cancer develops due
to DNA damage and genetic
mutations that can be
influenced by exposure to
estrogen. Sometimes there
will be an inheritance of
DNA defects or pro-
cancerous genes like
BRCA1 and BRCA2. Thus
the family history of ovarian
or breast cancer increases
the risk for breast cancer
development.
 TYPES OF BREAST CANCER
Breast cancer can be categorised by whether it is non-invasive or invasive:

Non-invasive breast cancer (in situ)

Ductal carcinoma in situ (DCIS) is a pre-malignant lesion – it is not yet cancer, but can progress to become an invasive form of breast
cancer. In this type of cancer, the cancer cells are in the ducts of the breast but have not spread into the healthy breast tissue.

Lobular neoplasia (previously called lobular carcinoma in situ) is when there are changes in the cells lining the lobules, which indicate that
there is an increased risk of developing breast cancer in the future. Lobular neoplasia is not actually breast cancer, and although women
with lobular neoplasia will have regular check-ups,most will not develop breast cancer.

Invasive breast cancer

Invasive breast cancer is the name given to a cancer that has spread outside the ducts (invasive ductal breast cancer) or lobules (invasive
lobular breast cancer). These can be further classified by their histology; for example, tubular, mucinous, medullary and papillary breast
tumours are rarer subtypes of breast cancer.

Special types of invasive breast cancers

Some invasive breast cancers have special features or develop in different ways that influence their treatment and outlook.
These cancers are less common but can be more serious than other types of breast cancer.
 Types of Breast Cancer
Triple-negative breast cancer
Triple-negative breast cancer is an aggressive type of invasive breast cancer in which the cancer cells don’t have estrogen or
progesterone receptors (ER or PR) and also don’t make any or too much of the protein called HER2. (The cells test"negative" on
all 3 tests.) It accounts for about 15% of all breast cancers and can be a difficult cancer to treat.

Inflammatory breast cancer

Breast cancer is also categorised by how advanced the disease is:

Early breast cancer

Breast cancer is described as early if the tumour has not spread beyond the breast or axillary lymph nodes(also known as Stage 0 IIA breast
cancer). These cancers are usually operable and the primary treatment is often surgery to remove the cancer, although many patients also have
preoperative neoadjuvant systemic therapy.

Locally-advanced breast cancer

Breast cancer is locally-advanced if it has spread from the breast to nearby tissue or lymph nodes (Stage IIB-III). In the vast majority of
patients, treatment for locally-advanced breast cancer starts with systemic therapies.Depending on how far the cancer has spread, locally-
advanced tumours may be either operable or inoperable (in which case surgery may still be performed if the tumour shrinks after systemic
treatment).

Metastatic breast cancer

Breast cancer is described as metastatic when it has spread to other parts of the body, such as the bones, liver or lungs (also called Stage IV).
Tumours at distant sites are called metastases. Metastatic breast cancer is not curable but is treatable.
 Types of Breast Cancer

Advanced breast cancer

Advanced breast cancer is a term used to describe both

locally-advanced inoperable breast cancer and metastatic
breast cancer.

Subtypes based on hormone receptor status and

HER2 gene expression
 SIGNS AND SYMPTOMS OF BREAST CANCER
• Often found as an abnormality on mammogram
• Painless firm mass
• Persistent changes to the breast
– Thickening
– Swelling
– Dimpling
• Cooper’s ligament affected
– Distortion
– Tenderness
– Skin irritation
– Redness
– Scaling
– Prominent superficial veins
Signs and Symptoms of Breast Cancer
• Nipple changes
– Ulceration
– Retraction, inversion
– Spontaneous discharge
 • SPREAD OF DISEASE
– Travels along the ducts (carcinoma in situ)
– Eventually breaking through the basement membrane (invasive
carcinoma)
• Invades adjacent lobules, ducts, fascial strands, & mammary fat
• Spreads through breast lymphatics into peripheral lymphatics
– Can grow through blood vessel walls and spread into the deep
lymphatics of the dermis (skin)
• Edema and dimpling of the skin (peau d’orange)
– Ulceration and infiltration of the overlying skin
 Spread of disease
• Lymph node spread of disease
– LN involvement increases with:
• Increasing tumor size
• Histological nuclear grade
(moderate or poorly
differentiated)
• Presence of lymphovascular
invasion
• Age < 60y/o
• African American race
– Usually goes to axillary LN levels
I and II, before reaching level III,
the supraclavicular LNs, or the
internal mammary LNs.
 SPREAD OF DISEASE
• Distant spread of disease
– Most common site
• Bone
– Other sites:
• Lungs
• Lung pleura
• Liver
• Brain/CNS
– Local control of disease can impact
systemic metastasis and survival, as
well as cosmesis and quality of life
 HOW IS BREAST CANCER DIAGNOSED?
Breast cancer is usually diagnosed by clinical examination,
imaging and biopsy.
Investigation of choice for Diagnosis: Tru-Cut Biopsy.
Investigation of choice for Staging: PET-CT

Clinical examination
• Physical exam
– Sitting and supine
– Size, symmetry, pigmentation, scaling or discharge from the
nipple, dilated veins or edema of the skin
– Location, size, consistency, tenderness, and mobility of a
palpable
tumor
– Axillary, supraclavicular, and infraclavicular LNs
 IMAGING:
Ultrasound
If you have noticed a change in your breasts or a mammogram has detected
an abnormality, your doctor may arrange a breast ultrasound for you. A
breast ultrasound is a non-invasive, painless test that uses sound waves to
form an image of structures in the breast, which helps your healthcare
provider determine whether these changes are caused by a non-cancerous or
benign lump of tissue or a breast cancer based upon the shape, location and
other characteristics visible on ultrasound. Occasionally the ultrasound can
be inconclusive, and your doctor may request follow up ultrasound to
monitor the lump and/or request a biopsy.
Can ultrasound detect breast cancer? Yes, however, some ultrasounds may
be inconclusive and there may be other tests your doctor requests you to
take in addition to the ultrasound, such as a biopsy to deliver a full
diagnosis.
To detect abnormalities in the breast, ultrasound machines send high-
frequency sound waves towards the tissue while receiving those waves that
echo/bounce back. The images of the breast tissue are created by these
reflected sound waves, which are dependent on the internal structures of
your breast/s such as boundaries between fluid and soft tissue or between
bone and soft tissue.
Mammography:
Imaging techniques used for women in whom breast cancer is suspected
include mammography, ultrasound and/or MRI scan:
Mammography has been associated with:
– Detection of earlier stage breast cancers
– Reduction in breast cancer mortality rates
• Mammography for all woman:
– Sensitivity: ~90% (60-95%)
– Specificity: ~94% (50-98%)
– Positive Predictive Value: 8-14% for all screened patients, higher
for symptomatic patients
• Screening Mammogram
– Routine images in asymptomatic women
– 2 views: craniocaudal and mediolateral obliques of each breast
• Diagnostic Mammogram
– Used to characterize abnormalities detected at screening or in
women with palpable masses
– Additional magnification views
– Generally done with the radiologist present to determine the need
for additional views and/or follow-up studies.
Mammographic Findings
• Ductal carcinoma in situ
– Clusters of microcalcifications (> 5)
– Calcifications
• 100-300 μm in size
• Rod-like, tubular, branching, or
punctate.
• Invasive carcinoma
– Ill-defined mass with spiculated
margins
– Linear, radiated, or spiculated
changes around a central focus
Limitations of Mammography
• Reduced sensitivity for dense breasts
• Sometimes difficult to determine extent of disease in the
breast
• May miss small lesions and certain histologies
– E.g. Invasive lobular carcinoma
 MRI SCAN:
MRI has been found to be more sensitive than
mammogram
and clinical breast exams in detecting invasive breast
cancer in women at high risk for familial breast cancer
• Increased age is an independent risk factor for breast
cancer
• Further evaluation of the value of MRI in detecting occult
malignancies in the contralateral breast in women > 70 y/o
– Retrospective review
– 159 women > 70 y/o, with newly diagnosed breast cancer
– 9 (5.7%) women were found to have synchronous,
pathologically confirmed, otherwise occult malignances in
the
contralateral breast.
• Limitations of Breast MRI:
– Expensive
– Higher recall rates
– Higher false positive rates because of lower specificity than
Mammography
Indications for Breast MRI
• Screening for breast cancer in certain moderate to high risk
patient populations (American Cancer Society)
• Evaluation of breasts with increased density
– More sensitive than mammography
• Monitoring treatment response to neoadjuvant chemotherapy
• Monitoring women with a personal history of breast cancer
– Evaluate the extent of disease in the ipsilateral breast
– Evaluate the presence of disease in the contralateral breast
• Aid in surgical planning for breast cancer treatment
– Evaluate for the presence
of disease in multiple quadrants of the same breast (multicentric)
– Breast conserving therapy (BCT) vs. mastectomy
 BIOPSY:
A tumour biopsy gives the doctor information about the type of breast cancer present and helps to
plan treatment.
Fine needle aspiration biopsy
Core needle biopsy
Image-guided biopsy
Surgical biopsy

A breast biopsy is a procedure to remove a sample of breast tissue for testing. The tissue sample is
sent to a lab, where doctors who specialize in analyzing blood and body tissue (pathologists) examine
the tissue sample and provide a diagnosis.
A breast biopsy might be recommended if you have a suspicious area in your breast, such as a breast
lump or other signs and symptoms of breast cancer. It can also be used to investigate unusual findings
on a mammogram, ultrasound or other breast exam.
The results of a breast biopsy can show whether the area in question is breast cancer or if it's not
cancerous. The pathology report from the breast biopsy can help your doctor determine whether you
need additional surgery or other treatment.
Why it's done
Your doctor may recommend a breast biopsy if:
•You or your doctor feels a lump or thickening in the breast, and your doctor suspects breast cancer
•Your mammogram shows a suspicious area in your breast
•An ultrasound scan or breast magnetic resonance imaging (MRI) reveals a suspicious finding
•You have unusual nipple or areolar changes, including crusting, scaling, dimpling skin or a bloody
discharge
TUMOR MARKERS OF BREAST CANCER
BIRADS SCORE (BREAST IMAGING RECORDING AND DATA SYSTEM
TNM STAGING
 BREAST CANCER TREATMENT:
Most women undergo surgery for breast cancer and many
also receive additional treatment after surgery, such
as chemotherapy, hormone therapy or radiation.
Chemotherapy might also be used before surgery in certain
situations.
Surgery

myomectomy surgery

A mastectomy is surgery to remove all breast tissue from a

breast. It's most often done to treat or prevent breast cancer.
In addition to removing the breast tissue, mastectomy also
may remove the breast skin and nipple. Some newer
mastectomy techniques can leave the skin or nipple. These
procedures may help improve the appearance of the breast
after surgery.
 MASTECTOMY FOR BREAST CANCER
TREATMENT
A mastectomy may be a treatment option for many types of breast cancer. Mastectomy might be
the first treatment for:

Ductal carcinoma in situ, also called DCIS or noninvasive breast cancer.

Stages 1 and 2 breast cancer, also called early-stage breast cancer.
Paget's disease of the breast.
Breast cancer that comes back after treatment, also called locally recurrent breast cancer.
For some types of breast cancer, a mastectomy happens after chemotherapy, such as for:

Stage 3 breast cancer, also called locally advanced breast cancer.

Inflammatory breast cancer.
 LUMPECTOMY
Lumpectomy (lum-PEK-tuh-me) is surgery to remove cancer or other abnormal tissue from
your breast.
During a lumpectomy procedure, the surgeon removes the cancer or other abnormal tissue and
a small amount of the healthy tissue that surrounds it. This ensures that all of the abnormal
tissue is removed.
Your doctor may not recommend lumpectomy for breast cancer if you:
•Have a history of scleroderma, a group of diseases that harden skin and other tissues and
make healing after lumpectomy difficult
•Have a history of systemic lupus erythematosus, a chronic inflammatory disease that can
worsen if you undergo radiation treatments
•Have two or more tumors in different quadrants of your breast that cannot be removed with a
single incision, which could affect the appearance of your breast
•Have previously had radiation treatment to the breast region, which would make further
radiation treatments too risky
•Have cancer that has spread throughout your breast and overlying skin, since lumpectomy
would be unlikely to remove the cancer completely
•Have a large tumor and small breasts, which may cause a poor cosmetic result
•Don't have access to radiation therapy
 SENTINEL NODE BIOPSY
Sentinel node biopsy is a procedure to see if cancer has spread. It can tell
whether the cancer cells have broken away from where they started and
spread to the lymph nodes. Sentinel node biopsy is often used in people
who have breast cancer, melanoma and other types of cancer.

The sentinel nodes are the first few lymph nodes to which cancer spreads.
In sentinel node biopsy, a tracer material is used to help the surgeon find
the sentinel nodes during surgery. The sentinel nodes are removed and
tested in a lab.

If the sentinel nodes are free of cancer, then cancer probably hasn't spread.
This means that removing additional lymph nodes is not necessary. More
surgery might not be needed.

If a sentinel lymph node biopsy shows cancer, you might need to have
more lymph nodes removed for testing.
Sentinel node biopsy is routinely used for people with:
•Breast cancer.
•Endometrial cancer.
•Melanoma.
•Penile cancer.
 AXILLARY LYMPH NODE
DISSECTION
An axillary lymph node dissection (ALND) is surgery to remove lymph nodes
from the armpit (underarm or axilla). The lymph nodes in the armpit are called
axillary lymph nodes. An ALND is also called axillary dissection, axillary node
dissection or axillary lymphadenectomy.
Why an axillary lymph node dissection is done
An axillary lymph node dissection is done to:
•check for cancer in the lymph nodes of the armpit
•find out how many lymph nodes contain cancer and how much cancer has
spread to them
•remove lymph nodes that contain cancer
•remove lymph nodes when there is a high chance that cancer will spread to
them
•reduce the chance that the cancer will come back (recur)
•remove cancer that is still in the lymph nodes after radiation therapy or
chemotherapy
•help doctors plan further treatment
 EXTERNAL BREAST PROSTHESES

There are two types of external breast prostheses:

Temporary external prostheses are fabric covered and fit into a specially designed bra. They are
comfortable and can be used immediately after a mastectomy.

Permanent external prostheses are made of silicone. Since their weight and appearance are similar
to natural breasts, they give your silhouette a natural shape. They can be attached directly to the
chest or inserted into a pocket bra.

Tips for choosing your external prosthesis:

Bring along a friend or relative who knows your shape and will give you their opinion.
Compare different models and prices.
Take your time to truly assess your options.
 BREAST RECONSTRUCTION SURGERY
There are two major types of breast reconstruction:

implant reconstruction – an implant is placed under the skin and muscle to recreate the shape of the breast
flap reconstruction – skin, fat and muscle are taken from elsewhere on the body to make the new breast.
TRAM flap
Transcutaneous rectus abdominus myocutaneous muscle (TRAM) flap reconstruction
DIEP flap reconstruction
Some surgeons now perform what is known as a deep inferior epigastric artery perforator (DIEP) flap reconstruction.
Skin flaps from other areas of the body
breast – this is known as breast-sharing reconstruction. Tissue from the remaining breast contributes to the reconstruction.
This is suitable for women with large breasts.
back – this operation may be preferred if the chest muscles were removed during the mastectomy. Muscle from the back
(latissimus dorsi, or LD flap) and the overlying skin are taken and used to form a breast shape. In many cases, the
reconstructed breast has to be filled out with an implant. The back is left with a visible scar and a slight hollowing near the
shoulder blade where the muscle was removed.
buttock – a small flap from the buttock (gluteus muscle) is sometimes taken if the abdominal skin isn’t sufficient. A vein
needs to be taken from one leg to secure a blood supply to the tissue in its new location on the chest wall.
Inner thigh – a transverse upper gracilis (or TUG) flap uses a flap of skin, fat and muscle from the upper inner thigh to
reconstruct a breast.
hip – a flap of skin from the hip may be used if the abdomen and buttock are unsuitable.
 RADIATION THERAPY
Radiation therapy for breast cancer uses high-energy X-rays, protons
or other particles to kill cancer cells. Rapidly growing cells, such as
cancer cells, are more susceptible to the effects of radiation therapy
than are normal cells.
The X-rays or particles are painless and invisible. You are not
radioactive after treatment, so it is safe to be around other people,
including children.
Radiation therapy for breast cancer may be delivered through:
•External radiation. A machine delivers radiation from outside
your body to the breast. This is the most common type of radiation
therapy used for breast cancer.
•Internal radiation (brachytherapy). After you have surgery to
remove the cancer, your doctor temporarily places a radiation-
delivery device in your breast in the area where the cancer once was.
A radioactive source is placed into the device for short periods of
time over the course of your treatment.
Radiation therapy may be used to treat breast cancer at almost every
stage. Radiation therapy is an effective way to reduce your risk of
breast cancer recurring after surgery. In addition, it is commonly
used to ease the symptoms caused by cancer that has spread to other
parts of the body (metastatic breast cancer).
 CHEMOTHERAPY
Chemotherapy is the use of drugs to destroy cancer cells, usually Common drugs for breast cancer include:
by keeping the cancer cells from growing, dividing, and making 1. Capecitabine (Xeloda)
more cells. It may be given before surgery to shrink the tumor or 2. Carboplatin (Paraplatin)
after surgery as an adjuvant treatment. It is also used to treat 3. Cisplatin (Platinol)
metastatic breast cancer and cancer that returns after treatment, 4. Cyclophosphamide (Neosar)
5. Docetaxel (Docefrez, Taxotere)
called recurrent cancer. A medical oncologist, a doctor who
6. Doxorubicin (Adriamycin)
specializes in treating cancer with medication, prescribes
7. Epirubicin (Ellence)
chemotherapy. 8. Eribulin (Halaven)
Systemic chemotherapy is delivered through the bloodstream to 9. Fluorouracil (5-FU, Adrucil)
reach cancer cells throughout the body. Chemotherapy for breast 10. Gemcitabine (Gemzar)
cancer may be given through an intravenous (IV) tube placed into 11. Ixabepilone (Ixempra)
a vein or as a pill or capsule that is swallowed (orally). Patients 12. Methotrexate (multiple brand names)
may have treatment once a week, once every 2 weeks (also called 13. Paclitaxel (Taxol)
dose-dense chemotherapy), once every 3 weeks, or even once 14. Pegylated liposomal doxorubicin (Doxil)
15. Protein-bound paclitaxel (Abraxane)
every 4 weeks. 16. Vinorelbine (Navelbine)
A patient may receive 1 drug at a time or a
combination of different drugs given at the same time.
The type of chemotherapy a person receives and how
often it is given will depend on what worked best in
clinical trials for that type and stage of cancer.
 ENDOCRINE THERAPIES
Endocrine therapies aim to reduce the effects of oestrogen in ER positive breast cancers. This
is the most important type of systemic treatment for ER positive tumours, also called hormone-
dependent tumours.
There are a number of types of endocrine therapy available, which are taken orally or
administered as an injection:
• Selective oestrogen receptor modulators (SERMs) block ER on breast cells to prevent
oestrogen attaching to the receptors. Tamoxifen is a type of SERM.
• Selective oestrogen receptor downregulators (SERDs), such as fulvestrant, work in a similar
way to SERMs, but also reduce the number of ERs.
• Ovarian function suppression by gonadotropin-releasing hormone analogues or by surgery
maybe offered to pre- and perimenopausal women to reduce the supply of oestrogen from the
ovaries to the tumour.
• Aromatase inhibitors reduce the production of oestrogen in tissues and organs other than the
ovaries,and is therefore effective only in postmenopausal women, unless the function of the
ovaries is suppressed (oestrogen levels are artificially lowered) in premenopausal women.
Anastrozole, letrozole and exemestane are all aromatase inhibitors.
 TARGETED THERAPY
Targeted therapies are drugs that block specific signalling pathways in cancer cells that encourage them to grow. A
number of targeted therapies are used in the treatment of breast cancer:
• Anti-HER2 agents act on the HER2 receptor to block signalling and reduce cell proliferation in HER2 positive
breast cancers. Trastuzumab, lapatinib, pertuzumab and trastuzumab emtansine (TDM-1) are all currently-used
anti-HER2 agents. Neratinib is a new anti-HER2 agent that may also be used to treat HER2 positive disease.
• Inhibitors of cyclin-dependent kinases 4/6 (CDK4/6) reduce cellular proliferation in tumours.Palbociclib,
ribociclib and abemaciclib are CDK4/6 inhibitors used in the treatment of breast cancer.
• Inhibitors of mechanistic target of rapamycin (mTOR), such as everolimus, reduce the growth and proliferation of
tumour cells stimulated by mTOR signalling.
• Inhibitors of poly ADP-ribose polymerase (PARP) make it difficult for cancer cells to fix damaged DNA,which can
cause cancer cells to die. Olaparib and talazoparib are new PARP inhibitors that may be used to treat some patients
with a BRCA mutation.
• Vascular endothelial growth factor (VEGF) inhibitors, such as bevacizumab, stop tumours from stimulating
blood vessel growth within the tumour, thereby starving them of the oxygen and nutrients they need to continue
growing.
 BREAST CANCER SCREENING
Woman < 40 y/o
– May begin Breast Self Exams (BSE) at 20 y/o
• To recognize the normal texture of their breasts
• To be able to report any breast changes to their physician
– Clinical Breast Exam (CBE) every 3 yrs.
• Women at high risk
– > 20% lifetime risk of breast cancer
– Proven mutation in BRCA1 or BRCA2
– First-degree relative (parent, brother, sister, or child) with a BRCA1
or BRCA2 gene mutation
– Radiation therapy to the chest between the ages of 10-30 years old
– Personal history or family history in a first-degree relative of
• Li-Fraumeni syndrome
• Cowden syndrome, or
• Bannayan-Riley-Ruvalcaba syndrome
– Recommendations:
• Begin screening at age 30 y/o
• Annual mammogram and MRI
• Annual Clinical Breast Exam
• For patients who have BRCA1 or BRCA2 mutations
– Annual pelvic exams with transvaginal U/S of the ovaries, and Ca-125
 PROGNOSIS:
The prognosis of early breast cancer is
quietly good. Stage 0 and stage I both
have a 100% 5-year survival rate. The 5-
year survival rate of stage II and stage III
breast cancer is about 93% and 72%,
respectively. When the disease spreads
systemically, its prognosis worsens
dramatically. Only 22% of stage IV breast
cancer patients will survive their next 5
years.
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