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Introduction
  • Most common cancer and second most common cause of death in adult women
    • 12% lifetime risk
  • BRCA1 and BRCA2 mutations are associated with multiple / early onset breast and ovarian cancer.
  • Incidence:
    • most common in the elderly
    • 50% of all breast cancer occur in woman over the age of 65
    • 20% among woman under 50
    • 2% in woman less than 30 
    • 75% have no risk factors
  • Risk factors include:
    • increasing age
    • breast cancer in first degree relatives or mother with breast cancer
    • low fiber, high fat diet
    • obesity
    • history of contralateral breast cancer
    • a history of endometrial cancer which is also a estrogen induced cancer
    • h/o radiation
    • increases # menstrual cycles or exposure to estrogen
      • nulliparity 
      • early menarche (<11 yo.)
      • late menopause (>50 yo.)
      • late first pregnancy (>30 yo)
  • Physical/anatomic risk factors include: (CHAFED LIPS)
    • C: cancer in breast
    • H: hyperplasia
    • A: atypical hyperplasia
    • F: female
    • E: elderly
    • D: DCIS
    • L: LCIS
    • I: inherited genes
    • P: papilloma
    • S: sclerosing adenitis
  • Prevention 
    • smoking cessation
    • alcohol cessation
    • exercise
    • breastfeeding
Presentation
  • Presents with:
    • asymptomatic
    • breast lump
    • nipple discharge 
      • especially bloody, unilateral
  • Most often presents in upper/outer quadrant
  • Physical Exam shows:
    • firm immobile, painless lump
    • some skin changes (redness, ulcerations, edema, nodularity)
      • skin retraction indicates involvement of Cooper's ligament
    • axillary lymohadenopathy in more advanced cases
    • breast skin edema with dimpling (peau d' orange)  is a finding with a poor prognosis
      • represents obstruction of the lymphatics cancer
Evaluation
  • Combination of the physical exam, mammography, and fine-needle aspiration is highly accurate
    • ultrasound is sometimes used to see if the mass is cystic  
  • Labs include
    • serum calcium level
    • alkaline phosphatase
    • check for estrogen and progesterone receptors
TMN Staging
  • Staging is done with the TNM system and imaging (CT/bone scan)
> 5cm
Stage IIB
Stage IIIA
Stage IIIA
Stage IV
2-5 cm
Stage IIA
Stage IIB
Stage IIIA
Stage IV
< 2cm
Stage I
Stage IIA
Stage IIIA
Stage IV
 
No nodes
Mobile axilalry nodes
Fixed axillary nodes
Distant mets (including ipsilateral supraclavicular nodes)


Types of Breast Cancer

Carcinoma in situ
LCIS LCIS 
DCIS DCIS 
DCIS Paget's Breast Disease 
Invasive carcinoma
DCIS Invasive Lobular Carcinoma 
DCIS Invasive Ductal Carcinoma 
DCIS Inflammatory Carcinoma 
DCIS Cystosarcoma Phyllodes 

Mammogram Screening
  • Highly effective screening tool except in young women
    • dense breast tissue in young woman interferes with specificity and sensitivity
    • most effective in postmenopausal patients because of less glandular breast
  • All women aged 50-74 should have mammograms every 1-2 years
    • controversial whether screening mammography should begin as early as age 40
  • Women with with first degree relatives with cancer should begin screening ten years before family member developed cancer
  • Women with breast implants should undergo the same screening schedule as women without implants
 

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