1 / 75

Underwriting Breast Cancer Steven E. Zimmerman M.D. Vice President & Chief Medical Director

Underwriting Breast Cancer Steven E. Zimmerman M.D. Vice President & Chief Medical Director Breast Cancer Statistics – 2008 The most common cancer in females 250,230 new cases estimated 182,460 invasive breast cancers 67,770 in situ breast cancers

Rita
Télécharger la présentation

Underwriting Breast Cancer Steven E. Zimmerman M.D. Vice President & Chief Medical Director

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Underwriting Breast CancerSteven E. Zimmerman M.D.Vice President & Chief Medical Director

  2. Breast Cancer Statistics – 2008 • The most common cancer in females • 250,230 new cases estimated • 182,460 invasive breast cancers • 67,770 in situ breast cancers • Second only to lung cancer in mortality for females • 40,930 estimated deaths from breast cancer in 2008 • Leading cause of death for American females between ages 40-55 • Lifetime risk is 1 in 7

  3. Annual Incidence of Female Breast Cancer (1975-2004) Ravdin P et al. N Engl J Med 2007;356:1670-1674

  4. Risk Factors for Breast Cancer • Age • Familial (5 to 10% of all cases; ½ BRCA 1/2) • 1ST degree relative – 1.5 to 3x increased risk • BRCA 1/2 mutation – 26 to 85% lifetime risk • Hormonal factors • Estrogen exposure (HRT, serum estrogen levels) • Reproductive history • Early menarche • Late menopause • Nulliparity

  5. Risk Factors for Breast Cancer • Benign breast disease • Atypical hyperplasia • Dietary and lifestyle factors • Alcohol consumption • Dietary fat intake • Environmental factors • Radiation exposure • Greatest when exposure occurs at young age • Risk is greatest in young women treated for Hodgkin’s Lymphoma with mantle radiation

  6. Breast Cancer Trends – Incidence by Age

  7. Absolute Risk of Breast Cancer and Age

  8. Breast Cancer Incidence, Hormone Receptor Status and Hormone Replacement Therapy Ravdin P et al. N Engl J Med 2007;356:1670-1674

  9. 15%-20% 5%–10% Sporadic Family clusters Hereditary How Much Breast Cancer Is Hereditary?

  10. Cancer Arises From DNA Mutations in Cells Normal cell DNA mutations Uncontrolled proliferation Last DNA mutation from: • heredityor • radiation or chemicalsor • spontaneous errorsduring DNA duplication

  11. BRCA Mutations • Highest prevalence in Ashkenazi Jewish population • Tumor suppressor genes • BRCA1 • Associated with ~45% of inherited breast cancer & over 80% of inherited breast and ovarian cancer • Location – chromosome 17 • BRCA2 • Associated with male breast cancer, prostate cancer, and GI malignancies as well • Location – chromosome 13

  12. Causes of Hereditary Susceptibility Contribution to Hereditary Breast Cancer 20% - 40% 10% - 30% <1% <1% 30% - 70% Gene BRCA1 BRCA2 TP53 PTEN Undiscovered genes

  13. Genes Associated with a Hereditary Predisposition to Breast Cancer Robson M and Offit K. N Engl J Med 2007;357:154-162

  14. Magnitude of Relative Risk

  15. Detecting & Diagnosing Breast Cancer • Breast self examination (BSE) • Physical examination • Mammography • Ultrasonography • Magnetic resonance mammography (MRM)

  16. U.S Preventive Services Task Force Nelson, H. D. et. al. Ann Intern Med 2005;143:362-379

  17. Mammography • Detection of calcifications • Microcalcifications • Common sign of cancer, e.g. DCIS • Macrocalcifications • More typical of benign disease • Mass – with or without calcification • Issues with: • Dense breasts • Implants

  18. Mammographic Findings

  19. Mammographic Findings

  20. Breast Ultrasonography • Not used for screening • Used to evaluate suspicious lesions – palpated and/or seen on mammography • Differentiates cystic from solid lesions • Distinguish tumor from lymph nodes

  21. Breast Ultrasonography

  22. Breast Ultrasonography

  23. Breast MRI • More sensitive than mammography • Advantages • Dense breasts • Implants • Young women • Hereditary risks • Prior lumpectomy • Disadvantages • Less specific – more false positives • More expensive

  24. Breast MRI Fibroadenoma – before contrast Invasive Lobular Ca – before contrast

  25. Breast MRI Fibroadenoma – 5 minutes after contrast Invasive Lobular Ca – 5 minutes after contrast

  26. Breast MRI Fibroadenoma – subtracted image Invasive Lobular Ca – subtracted image

  27. Impact of Screening Age-standardized incidence of and mortality from female breast cancer, England and Wales, Rate per 100,000

  28. Anatomy of the Breast

  29. Normal Breast Tissue

  30. Benign Breast Disease • Fibroadenoma • Fibrocystic disease • Atypical hyperplasia • Other

  31. Benign Breast Disease - Fibroadenoma • Usually in women under age 30 • Rounded, easily movable mass • About 10% will disappear per year • Small long term risk for developing cancer

  32. Benign Breast Disease – Fibrocystic disease • Gross cyst • Usually in 40’s • Needle aspiration or ultrasound for diagnosis • Non-bloody fluid obtained, then lump disappears

  33. Benign Breast Disease – Fibrocystic disease • Fibroadenosis & Micro cysts • Found in 30’s & 40’s • Disappears after menopause • Usually diffuse and ill-defined • Usually cyclic with menses • Painful and prominent before; resolves after

  34. Benign Breast Disease – Atypical hyperplasia • Marked proliferation and atypia of epithelium • Found in 3% of benign breast biopsies • Associated with 13% subsequent development of breast cancer – 4x risk factor • Diagnosed by same criteria as DCIS, but doesn’t have all the characteristics • Some may be under-diagnosed DCIS

  35. Benign Breast Disease – Other • Phylloides tumor • Unpredictable behavior • About 10% metastasize from either malignant or benign phylloides tumors • Mammary duct ectasia • Breast inflammation and abscess formation • Presents as periareolar inflammation • When chronic, most frequent cause of nipple discharge in premenopausal women

  36. Benign Breast Disease – Other • Papillomas • Small (< 1cm) intraductal growths • Frequently have nipple discharge • May be solitary or multiple • Frequently develop more papillomas or cancer • Single without atypia – 3-fold risk • With atypical hyperplasia – 4-fold risk • Multiple often associated with carcinoma

  37. Presenting Symptoms of Breast Cancer • Painless breast mass 66% • Painful breast mass 11% • Nipple discharge 9%

  38. Breast Cancer • Lobules and Ducts are structures within the breast • Cancer seen only in the ducts = ductal • Cancer seen only in the lobules = lobular • Tumor confined to the ducts or lobules = in situ • Cancer extending beyond the ducts or lobules to adjacent tissue = invasive or infiltrating

  39. Breast Cancer – Non-infiltrating (in situ) • Lobular carcinoma in situ – “not a cancer?” • Usually an incidental finding • Low risk of developing invasive breast cancer • More common in premenopausal women • Treatment is usually observation • Breast examination every 6-12 months • Mammogram every 1-2 years • Ductal carcinoma in situ (DCIS) • Diagnosed with increased frequency due to mammography • Subtypes • solid, cribiform, papillary, comedo • High grade and comedo type (usually) can travel extensively but undetected throughout the breast

  40. A – Normal cells B – Lobular cancer cells C – Basement membrane Lobular Carcinoma in situ

  41. A – Normal cells B – Ductal cancer cells C – Basement membrane Ductal Carcinoma in situ

  42. Papillary Solid Cribiform Comedo DCIS - Subtypes

  43. Normal Breast Tissue

  44. Pathology – DCIS

  45. Breast Cancer - Infiltrating • Infiltrating ductal carcinoma • Most common form – 70-80% • Invades breast structures and may spread to lymph nodes and to other organs • Same subtypes as DCIS • Infiltrating lobular carcinoma • Less common – 10-15% • Most common in 45-55 year age group • Sometimes bilateral; often without a lump

  46. Breast Cancer - Infiltrating • Paget’s disease of the breast • Uncommon – 1-2% • Red, scaly rash involving the nipple • Nipple may be inverted • May be a discharge • About 50% with underlying lump • If no lump, 60% will be in situ cancers

  47. A – Normal cells B – Invading ductal cancer cells C – Basement membrane Infiltrating Ductal Carcinoma

  48. A – Normal cells B – Invading lobular cancer cells C – Basement membrane Infiltrating Lobular Carcinoma

  49. Vascular and Lymphatic Invasion Lymphatic channel Blood vessels

More Related