• Contained in cells lining milk ducts
• Precancerous
• If someone has DCIS, they are considered to have active cancer

• Found in milk producing areas
• Usually found incidentally on biopsy
• Do not show up on mammrogram
• If someone has LCIS, they considered high risk for developing cancer somewhere
• Biggest risk factor for developing breast cancer

• 70% of all breast cancer
• Worst prognosis

• 10% of all breast cancers

• Fast growing
• Very aggressive
• Treatment time is of the essence

• Age > 40
• Breast cancer in 2 or more 1st relatives
• Hyperplasia w/ atypia
• LCIS
• Klinefelter's syndrome in men (XXY chromosomes)

• Mother w/ breast cancer before age 60
• First live birth after age of 25
• Used oral contraceptives > 4 yrs before pregnancy
• Ovarian cancer in one or more 1st degree relatives
• Menopause after the age of 55
• EtOH > 3 drinks/day

• Mother w/ breast cancer after age 60
• Breast cancer in 2nd degree relative
• Early menarchy (< 12 yo)
• Obesity (10th percentile) AND age 50
• Postmenopausal estrogen replacement
• EtOH 1-3 drinks/day

• Solitary, unilateral, irregular, nonmobile, painless lump is 1st sign in 90% of women
• Stabbing/aching pain
• Nipple discharge
• Nipple retraction
• Edema
• Redness/warmth

• Primary tumor size
• Number and extent of nodal involvement
• Response to primary therapy
• ER/PGR positive
• Histological grade
• Proliferative rate
• HER2/neu negative
• Other genetic mutations

Mammogram

• women at least 40 yo should have yearly mammograms

Clinical Breast Exam

• 20-39 = every 3 yrs
• At least 40 yo = yearly

Self Breast Exam

• Monthly starting at age 20

Surgical

• Prophylactic mastectomy decreases risk by 90%
• Oopherectomy before age 50 decreases risk by 50%

Chemical

• Tamoxifen 20 mg daily for 5 yrs
• Raloxifene 60 mg daily for 5 yrs

• Multimodality Treatment Approach
• Surgery with axillary lymph node dissection is the basis of therapy for non-advanced disease
• Patients who are ER/PGR positive should receive hormonal therapy
• The goal is CURE in patients with stage III or better disease
• Almost everyone gets chemotherapy +/- trastuzumab

Lumpectomy

• Only tumor and surrounding tissue removed

Mastectomy

• Removes entire breast and surrounding tissue
• Usually just one sided (unilateral)
• In advanced disease, both sides removed

• Tumor > 5 cm
• Positive surgical margins
• Positive lymph nodes
• Lumptectomy

• History and physical every 3-6 months for first 3 yrs, then every 6-12 months for 2 yrs, and annually thereafter
• Monthly SBEs
• Yearly mammography and gynecologic exams

• Treat with different chemotherapy agents --> can use combo therapy
• Give trastuzumab if HER2 positive and haven't received trastuzumab before
• Chemotherapy for recurrence should include anthracycline or taxane if haven't used before
• If had hormonal therapy before, change agents

• Doxorubicin + Cyclophosphamide
• Historically first line chemo
• Least complicated
• Best tolerated of anthracycline regimens that lack taxanes
• Dox and Cyclo on day 1 -- repeat cycle every 21 days for 4 cycles

• Same as AC, followed by paclitaxel
• Previously recommended for patients with positive lymph nodes
• In reality, is there a benefit?

• Same as AC, given with docetaxel

• Carboplatin/Paclitaxel
• Carboplatin/Docetaxel
• CMF = Cyclophosphamide + MTX + 5-FU
• Cyclophosphamide/Docetaxel
• Capecitabine/Docetaxel (cost is biggest draw back)

Quick

• Extravasation injury
• Hypersensitivity

Short Term

• Red secretions
• NV
• Myelosuppression
• Alopecia

Long Term

• Cardiac toxicity
• Liver toxicity

• BLACK BOX hypersensitivity
• BLACK BOX cardiotoxicity
• DO NOT give same time as anthracyclines
• HA, NV, diarrhea, periperhal edema