File #2

1. Oncology Rehabilitation: Web-based Learning for Physical Therapists Who Provide Rehabilitation to Patients with Breast Cancer File #2 Basic Breast Cancer

2. Basic Breast Cancer • General oncology information that will assist physical therapists who desire to work with patients diagnosed with breast cancer.

3. Who can get Cancer? • Anyone • 1,382,400 new diagnosed cases/year • 269,730 new breast cancer/year • 1 in 7 women are diagnosed with breast cancer (www.cancer.org, 2006)

4. Cancer2nd most common cause of death in the United States • Uncontrolled growth and spread of abnormal cells can result in death. • Over 9.8 million Americans alive today have a history of cancer. (3 million in 1971) • About 547,000/year people will die of cancer. • About 500,000 (4 of 10) people diagnosed with cancer will be alive in 5 years. (www.cancer.org, 2006)

5. Breast Cancer Specific: • The American Cancer Society estimates in 2006 that … • there will be 212,920 new cases of invasive breast cancer to be diagnosed, and 61,980 non-invasive cases. • approximately 40,970 females are expected to die from breast cancer. • about 1,720 cases of breast cancer expected in men, accounting for <1% of all breast cancer. Approximately 460 men will die of this diagnosis. • The National Cancer Institute estimates about 2.3 million women with a history of breast cancer were alive in 2002. (American Cancer Society, www.cancer.org, 2006)

6. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY • ONCOLOGY (Ong-kol’o-je) The sum of knowledge concerning tumors; the study of tumors. • CANCER (Kan’ser) A cellular tumor the natural course of which is fatal and usually associated with formation of secondary tumors. (Dorland, 1965)

7. What is Cancer? A large group of diseases • _________________________________ • _________________________________ • _________________________________ • _________________________________ • _________________________________ • “This knowledge is of significant importance to rehabilitation professionals, as they assist patients to realistically identify and achieve goals within their abilities and prognosis.” CDR. Charles L. McGarvey, M.S., P.T. Uncontrolled growth Abnormal cells that lack differentiation Uncontrolled spread of abnormal cells can result in death Detected and treated promptly, many types can be cured (Ward, 1995)

8. Normal Cell centriole mitochondrion nucleolus nucleus • Normal DNA • Normal growth • Normal function

9. Characteristics: • Exhibits uncontrolled growth • Invades surrounding tissue • Destroys healthy tissue • Mutates • Metastasizes • Becomes anaplastic • Has irregular shapes and patterns Cancer Cell • Abnormal DNA • Abnormal growth • Abnormal function

10. (Slide permitted by the American Cancer Society)

11. Benign: Occasionally large Light to dark staining Rare mitotic figures Round oval nucleus Smooth nuclear edge Nucleus intact Nucleoli small if present Multinuclear cells Clumps of cells similar Focus same windows between cells Malignant Many cells may be large Very basophilic Many mitotic figures Irregular (bizarre) nucleus Edges indistinct and irregular Nucleus disintegrated edges Large and prominent Vary in size and shapes Clumps vary in size 3-D must focus up and down to see cells; dark staining borders, no windows Cell Characteristics

12. Tissue Evaluation • Cell staining: • Cell cultures: Ability to dye parts of cells to make them clearer to inspect. Model for studying active cells in the whole organism or in vivo. .

13. Biopsy: • Fine-needle aspiration: • Cutting needle biopsy: • Incisional biopsy: • Excisional biopsy: Suction from syringe to gather clumps of cells from a tumor. Obtain small core of tissue Surgical removal of small area of tissue. Surgically remove entire tumor for analysis. (Altman, 1992)

14. Anatomic site of primary tumor (Lung, colon, breast). • Classification of the tissue of origin (Epithelium, connective tissue) • Extent of tumor progression (Degree of invasion or metastasis) • Degree of cell anaplasia (Benign or malignant) Tumor Nomenclature

15. Tumor - Localized swelling or mass • Benign: • Tumors can compress, invade and destroy adjacent normal tissue; do not invade other tissue and generallynot a danger to life. • Malignant: • Endanger life. Can choke out normal tissue, and spread to other parts of the body (Metastases) through the blood and lymph systems. (Dollinger et al, 2002)

16. Hyperplasia Dysplasia Metaplasia Anaplasia An increase in the number of cells of a tissue or organ without tumor formation. A cell variation in size and shape from normal. More severe than hyperplasia. Unusual cell growth. Differentiated tissue from one kind into another. Most serious growth. Absence of normal cellular differentiation in tissue. Cells divide at an increased rate compared to normal cells. Found in most malignancies. Cell Disorders (Otto, 2004)

17. Carcinoma • Develops in the lining and covering tissues of organs • 85 – 90% of all Cancers are generally found in organs that secrete • Examples: Lungs secrete mucus, breast secretes milk, pancreas secretes digestive juices Carcinoma in situ: Earliest stage of cancer, with the tumor confined to a local area. Sarcomasaccount for 2% of breast cancer. This is a solid tumor that originates in connective tissue, bone, muscle, cartilage or fat. : (Love, 1990)

18. Where breast cancer can develop: • Milk ducts • Between ducts • In fat • In lymphatic system • Blood vessels • Nipple • Lobes where milk is produced (Lang, 2005)

19. Ductal Inflammatory: Blockage of the lymph drainage from skin on the breast. Red, swollen, thick and pitted. Medullary: Invasive, well defined division of cancer and non-cancer tissue. Large Ca cells and immune system cells around the tumor border. Mucinous: Invasive cancer cells produce mucus and grows into a jelly-like tumor. Lobular Paget’s disease: Affects nipple and areola. Starts in milk duct as either in situ or invasive cancer. Good prognosis. 80% of breast cancers are invasive ductal carcinoma. Pathologic classifications of less common types of breast cancer: (Jennings-Dozier et al, 2002)

20. Signs of cancer and risk factors

21. 7 Warning Signs of Cancer • C change in bowel or bladder habits • A a sore that does not heal • U unusual bleeding or discharge • T thickening or lump in breast or elsewhere • I indigestion or difficulty swallowing • O obvious change in a wart or mole • N nagging cough or hoarseness (Dollinger, 2002)

22. Additional Warning Signs Specific to Breast Cancer Breast discharge or bleeding Change in shape of breast or nipple Tender lymph nodes Skin dimpling Noted rash or veins of the breast (Dollinger, 2002)

23. Risk Factors for Breast Cancer • Family history (less than 7% of breast cancers are thought to be hereditary). • Long menstrual cycles or early menarche • Late menopause • First pregnancy after age 30. • Higher education or socioeconomic class • Stress • Obesity • Living in Northern U.S. • History of colon or other female cancers. (Dollinger, 2002)

24. Differential Diagnosis: Before you treat, make sure the diagnosis is correct. • Differential diagnosis is the method by which a clinician considers the possible causes of a patient’s clinical findings before making a final diagnosis. • Patient with diagnosis of breast cancer: • Breast, lung and prostate carcinomas. • Be aware of any history of malignancy. • “Lymphedema is an important differential diagnosis in limb swelling” (Tiwari, 2003)

25. THINK……. LOOK FOR CANCER SIGNS

26. Breast Cancer Diagnosis Early detection is optimal

27. History & Physical Biopsy Fine Needle Aspiration Core Needle Biopsy Surgical Biopsy Mammogram MRI CT scan Ultrasound Bone scan PET Scan Tumor tests Methods to Diagnose Breast Cancer (Altman, 1992)

28. Diagnostic tools explained • Biopsies: • Fine Needle Aspiration – Removes cells through a thin hypodermic needle connected to syringe and moved in and out of tumor to acquire tissue for evaluation. Fluid is evaluated by a cytologist. This method used for a palpated lump, if negative further biopsies needed. • Core Needle Biopsy – A large needle which can yield a tissue sample. Needle insertion can be guided by ultrasound or a MRI scanner, which is called image-guided. This tissue study is completed by a pathologist. • Open biopsies are often prescribed to double check or rule out cancer. • Incisional biopsies remove tissue samples through a small incision, enough tissue for pathologist to confirm his conclusion. • Excisional biopsies remove the entire lump and some healthy tissue surrounding the lump. (Braddock, 2002)

29. Diagnosis continues • Mammogram is a technique completed routinely for early detection, This is completed by compressing the breast and obtaining an oblique and a craniocaudal view. Good procedure to spot lumps to small to be felt. Patterns of interspersed cords of cancer cells among the breast tissue make diagnosis and detection difficult. • Magnetic resonance imaging (MRI) Combination of magnetic and radio waves that are a high sensitivity device which can show the extent of the invasive or non-invasive disease. This procedure is completed by showing blood vessels in tissue. This tool is valuable for high risk females as well as following neoadjuvant therapy. • CAT scan is computer aided to create a three dimensional images of organs and structures for further specific diagnosis, if needed. • Ultrasound is a high frequency sound wave beamed through breast tissue and reflections are detected and turned into images. Cancer cells usually have a distinct outline compared to normal cells. The results of this examination are operator dependent. • Bone scan detects increased blood circulation in a bone, which could reveal metastases. • Pet Scan (Positron emission tomography) similar to X-ray except Pet scans show cell activity, by detecting the rate cells consume glucose. Cancer cells use up sugar faster than normal cells. • Tumor testing can be completed by using estrogen and progesterone receptors as well as other genetic measurements. (Dixon, 2006)

30. Mammography Radiologist read the test results and compare them to previous mammograms when possible.

31. Non-palpable intraductal carcinoma Mammogram (Slide permitted by the American Cancer Society)

32. Medullary carcinoma: Thought benign but mammogram and biopsy=suspicion of CA (Slide permitted by the American Cancer Society)

33. BREAST - Monthly breast self-exam between Age 20-40 Health professional breast check /3yrs • Age 40 - 1st mammogram • Age 40-50 - Health professional breast check/yr; mammogram every 1-2 yrs. • Over 50 = Health professional and annual mammogram SEE HEALTH CARE PROVIDER WITH ANY CHANGES IN BREAST Female Protection Against Cancer (Jennings-Dozier et al, 2002)

34. Male breast cancer • < 1% of breast cancer • 1500 new cases and 400 fatalities/year (Compared to 203,500 new cases in women) • Risk increases with family history of mutated BRAC2 • Prognosis similar to female, testing size, grade and nodes. • Treatment with mastectomy and other interventions as prescribed by oncologist. (Donegan, 2002)

35. * PATHOLOGY AND TUMOR STAGING

36. Specific Staging • To no palpable tumor • Tis cancer in situ • T1 < 2 cm T1a <0.5 cm • T1b >0.5 – 1 cm • T1c >1-2 cm • T2 > 2-5 cm • T3 > 5 cm • T4a involved chest wall • T4b involved skin • T4c T4a and T4b together • T4d inflammatory • No no regional node metastasis • N1 palpate morbile ipsilateral axillary nodes involved • N2 fixed ipsilateral axillary nodes • N3 ipsilateral internal mammary lymph node metastasis • Mo no distant metastasis • M1 distant metastasis (Dixon, 2006)

37. Classification leads to Stage • Stage 0 • Lobular carcinoma in situ (LCIS) abnormal cells lining a gland in the breast. • Ductal carcinoma in situ (DCIS) abnormal cells lining a duct; has risk of becoming invasive. Continue

38. Diagnostic Staging (TNM classification) (Abraham, 2005)

39. * • C TNM pre-op clinical diagnosis • P TNM post-surgical resection pathology • R TNM re-treatment staging--recurrence • A TNM autopsy (Otto, 2004)

40. Note decrease survival with increase stage (Slide permitted by the American Cancer Society)

41. Time Out Test • What was the expected total number of breast cancer expected in 2005? • Name the abnormal activities of cancer cells. • Removing cells and tissue for diagnosis is? • Once metastasis occurs what tumor grade is recorded? • Doubling refers to cancer growth? T/F • Carcinoma is a solid tumor? T/F Answers: 274,900 diagnosed; abnormal DNA, growth and function; biopsy; Grade 4; True; False (Sarcoma is a solid tumor).