Breast Cancer

Screening and Early Detection

Dr. Mohammed Tarawneh
Consultant Family Physician

What is Cancer?
A group of 100 different diseases
The uncontrolled, abnormal growth of cells
Cancer may spread to other parts of the
body

What is Breast Cancer?

The most common type of cancer in women in the Jordan and
the second most frequent cause of death from cancer in women
A disease in which normal cells in the breast begin to change,
grow without control, and no longer die
Cancer that has not spread is called in situ, meaning in place
Cancer that has spread is called invasive or infiltrating

Scope of Breast Cancer

Dr. Mohammed Tarawneh , Jordan-Amman, 2607/23/15

28 / 4 / 2010

Median Age at diagnosis of Female Breast cancer cases in some Arab

Countries
1996

50

1997

50

1998

50

1999

51

2000

51

2001

51

2002

50

2003

49

2004

49

2005

50

2006

51

2007

50

2008

51

53

49.6

51

47.6

51
45

Median Age in Developed Countries

6

49

48

46.4

65 years

Dr.Mohammed Tarawneh-NCDMOH-2010

07/23/15

Ten most common cancers among Jordanian Females,

07/23/15

Dr.Mohammed Tarawneh-NCDMOH-2010

Ten most common cancers among Jordanians

( both genders ) 2008

07/23/15

Dr.Mohammed Tarawneh-NCDMOH-2010

3606

6235

2332

07/23/15

Dr.Mohammed Tarawneh-NCD4466
MOH-2010

Number of registered Female breast cancer cases in Jordan, 1996-2008

X2

Year

1996

1997 1998

1999

2000

2001

2002

2003 2004

2005

2006 2007 2008

Projection !!! Breast Cancer in Jordan will increase by 1.5 every 10 years

Trend of Female breast cancer incidence (ASR) - Jordan

X

X 1.7

Projected
Projected

ASR / 100.000

Year

1996

2000

2005

2006

2007

2008

2020

11

Number of Cases

New Cases of Breast Cancer JNCR- Jordan

Projected

90%

Years

% of female
breast cancer
of all
female cancers

28.5%

32.7%

36.2%

34.8%

35.8%

36.7%

46%

12

Age-Standardized Rate of Female breast

cancer Jordan -2008- compared with some
countries

3 / 12

07/23/15

Dr.Mohammed Tarawneh-NCDMOH-2010

13

Incidence Rate /100.000 of Female Breast cancer

by Governorates , 2008

Central

North

07/23/15

Dr.Mohammed Tarawneh-NCDMOH-2010

South

14

Percentages of Female Breast Cancer

cases by Governorates -2008

Central

North

07/23/15

Dr.Mohammed Tarawneh-NCDMOH-2010

South

15

% Female Breast Cancer Jordan as compared with some countries

16

Dr.Mohammed Tarawneh-NCDMOH-2010

07/23/15

Age- group

% of Female Breast Cancer cases By Age-group during 1996-2008

17
07/23/15

Dr. Mohammed Tarawneh-NCD-MOH-2010

Percentages of Breast Cancer cases by laterality 1996-2008

1.4%

4.8%

45.4%
48.4%

07/23/15

Dr.Mohammed Tarawneh-NCDMOH-2010

18

Percentages of Breast cancer cases by Histopathological type- Jordan/2008

All
oth
er

Ad
en
oc
arc
in o

Infilt
ratin
g Lo
bula
r
Medu
lary

1.
4

4.
8

ma

Ty
pe
s

5.
9

Infiltrating Duct Carcinoma IDC

84.
7

IDC%
Lebanon 82.6% 07/23/15
Palestine 78.1%
KuwaitTarawneh-NCD79.4%
KSA 78.9% Oman 60%
Dr.Mohammed
MOH-2010
US SEER (1999-2001 ) 70.2%

Egypt 74%
19

Stages of Breast Cancer in Jordan based on JCR data

Stage 0
2.9%

Stage IV,
13.5%
Stage 0,
0.5%

Stage I
23.2%

Stage 1
6.7%

2007

Stage IV,
12.9%

Stage II
30.5%

Stage II
23.7%

2005

Stage
III
20.4%

9.5%
unknown
Stage 0
3.2%

Stage III
56.2%

Stage I

69%
Stages
111-IV

23.3%

2008
Stage II
28.8%

37.2%

Stage IV,
14.1%

Stage
III
23.1%
7.5%
unknown
20

What is the Structure of the Breast?

The breast is composed mainly of fatty

tissue, which contains a network of
lobes made up of tiny, tube-like
structures called lobules that contain
milk glands

Tiny ducts connect the glands, lobules,

and lobes, and carry the milk from the
lobes to the nipple

Blood and lymph vessels run

throughout the breast

About 90% of all breast cancers

originate in the ducts or lobes of the
breast

Overview
1) Biology of the development of breast cancer
2) Risk factors for breast cancer (in light of biology)
3) Potential for modification of breast cancer risk

Breast Cancer Arises

From The Interaction of
Two Processes
1) The Cancer Formation Process
2) The Process of Development
of the Breast

Latency Period, 20 years or more

Unspecialize
d
Cell

Initiated
Cell

Initiation

Benign
Tumor

Promotion

Malignant
Tumor

Progression

Proliferation
Mutation
Mutation
Cancer Gene Independence Invade & Spread

Stages of Cancer Formation

Development of the Breast Ductal Tree

Differentiation Occurs With Pregnancy
Birth

2 years

Proliferation

After
Puberty

Proliferation

After
Pregnancy

Proliferation
Differentiation

Cells at Risk Are Analogous

to a Targets Bulls-eye
Cells
at
Risk

Cells
at
Risk

Cells
at
Risk

Carcinogens

A larger number of cells at risk produces a larger

(and easier to hit) bulls-eye.

Interaction of a Cell at Risk

with a Carcinogen Can Produce
an Initiated Cell
An initiated cell is the first step
in formation of a tumor
Cells
at
Risk

For an initiated cell to become a

tumor both the Promotion and
Progression stages have to
occur
The larger the number of
initiated cells the higher the
breast cancer risk

What Are the Risk Factors

for Breast Cancer?

Age
Race
Individual or family history of breast cancer
A history of ovarian cancer
A genetic predisposition (mutations to the BRCA1 or
BRCA2 genes cause 2% to 3% of all breast cancers)
Estrogen exposure
Atypical hyperplasia of the breast
Lobular carcinoma in situ (LCIS)
Lifestyle factors (obesity, lack of exercise, alcohol use)
Radiation

Hereditary Breast Cancer

About 15% of breast cancers are inherited

Approximately 80% of hereditary breast cancer is caused by
mutations in the BRCA1 or BRCA2 genes
Women who inherit a BRCA mutation have a 50% to 85%
chance of developing breast cancer in their lifetime
Women with especially strong family history may consider
preventive surgery to remove breast tissue and/or
chemoprevention

Risk factors
Age

Adiposity

Gender

Diet

Family

history
Benign breast
disease
Reproductive factors
Endogenous
hormones
Exogenous hormones

Physical

activity

Alcohol
Radiation

Established Risk Factors

for Breast Cancer
Risk Factor

Relative Risk

Age Related
- Age (>50 vs <50 yr)
Reproduction Related
- Age of menarche (<12 vs >14 yr)
- Age of menopause (>55 vs <55 yr)
- Age at first birth (>30 vs < 20 yr)

6.5
1.2-1.5
1.5-2.0
1.3-2.2

Established Risk Factors

for Breast Cancer
Risk Factor
Environment Related
- Exposure to ionizing radiation
Breast Disease
- Breast Biopsy (any finding)
- Atypical hyperplasia

Relative Risk
1.0 - 8.7
1.5 - 1.8
4.0 - 4.4

Age at menarche
Later

age - lower risk

Age 15 vs age 11 gives 30% lower risk
to age 70
Lack of physical activity associated with
earlier menarche
Diet may play a role as might fewer
childhood infections

Menopause
Early

menopause reduces risk

High circulating hormones levels after
menopause increase risk, as does use
of postmenopausal hormones
Anti-estrogens may have a role
who is target population
how are they identified, counseled, etc.
balance risks vs. benefits

Hormonal exposure after

menopause
Obesity

is related to poor survival

Tamoxifen reduces mortality among
women with breast cancer
Tamoxifen and Raloxifene reduce risk of
breast cancer in randomized controlled
trials of breast cancer prevention

Weight and weight gain

Adult

weight gain increases risk of breast

cancer
Relation seen most clearly among
postmenopausal women who never have
used hormones
20 kg gain from age 18 associated with
doubling in risk of breast cancer vs. stable
weight

Physical activity
Evidence

from more than 30 studies

Typical reduction in risk with 4 hours per
week = 20% decrease in risk
Evidence present for pre and postmenopausal women
Barriers to physical activity include

neighborhood safety, time and family

responsibilities, social pressures

Breast Cancer and Early Detection

Early diagnosis means a better chance of
successful treatment
Mammography is the best tool doctors have to
screen for breast cancer
Many organizations recommend that women obtain
a mammogram each year, starting at the age of 40
Regular clinical breast examinations and breast
self-examinations are also recommended
Women are encouraged to discuss the frequency
of screening with their doctors

What Are the Symptoms of Breast Cancer?

New lumps or a thickening in the breast or under the arm

Nipple tenderness, discharge, or physical changes

Skin irritation or changes, such as puckers, dimples, or new creases

Warm, red, swollen breasts with a rash resembling the skin of an

orange

Pain in the breast (usually not a symptom of breast cancer, but should
be reported to a doctor)

No visible or obvious symptoms (asymptomatic)

How is Breast Cancer

Evaluated?
Screening and/or diagnostic mammography
Ultrasound
Magnetic Resonance imaging (MRI) scan
Biopsy is necessary to confirm a diagnosis
Blood tests are often used to determine if the cancer has spread
outside the breast
Additional tests may be used to determine stage

Breast Cancer Staging

Staging is a way of describing a cancer, such as the
depth of the tumor and where it has spread
Staging is the most important tool doctors have to
determine a patients prognosis
Staging is described by the TNM system: the size of the
Tumor, whether cancer has spread to nearby lymph
Nodes, and whether the cancer has Metastasized
(spread to organs such as the liver or lungs)
The type of treatment a person receives depends on the
stage of the cancer

Stage 0 Breast Cancer

Known as cancer in situ, meaning the cancer
has not spread past the ducts or lobules of the
breast (the natural boundaries)
Also called noninvasive cancer
Ductal carcinoma in situ (DCIS) is the most
common in situ breast cancer

Stage I Breast Cancer

The tumor is small and has not spread to the

lymph nodes

Stage IIa Breast Cancer

Stage IIa breast cancer
describes a smaller tumor
that has spread to the
axillary lymph nodes (lymph
nodes under the arm), or a
medium-sized tumor that
has not spread to the axillary
lymph nodes
Stage IIa may also describe
cancer in the axillary lymph
nodes with no evidence of a
tumor in the breast

Stage IIb Breast Cancer

Stage IIb breast
cancer describes a
medium-sized tumor
that has spread to the
axillary lymph nodes
Stage IIb may also
describe a larger
tumor that has not
spread to the axillary
lymph nodes

Stage IIIa Breast Cancer

Stage IIIa breast cancer describes any size tumor that

has spread to the lymph nodes

Stage IIIb Breast Cancer

Stage IIIb breast cancer has spread to the chest wall,

or caused swelling or ulceration of the breast, or is
diagnosed as inflammatory breast cancer

Stage IIIc Breast Cancer

Stage IIIc breast cancer has spread to distant lymph

nodes but has not spread to distant parts of the body

Stage IV Breast Cancer

Stage IV breast cancer can be any size and has

spread to distant sites in the body, usually the bones,
lungs or liver, or chest wall

Diet, Lifestyle and

Breast Cancer Risk

Vegetables and Fruits

Eating large amounts of vegetables, in general,
may be linked to a small decrease in breast
cancer risk
Evidence is stronger for a decrease in risk
with dark green and yellow vegetables
Vegetables may have a greater effect for
women with a family history of breast cancer
Eating fruit, in general, is unrelated to breast
cancer risk
Supplements do not appear to offer the
same protection as food

Anti-cancer Agents in Vegetables & Fruits

Inhibition of Initiation Stage of Cancer Formation

Latency Period, 20 years or more

Unspecialize
d
Cell

Initiated
Cell

Initiation

Benign
Tumor

Promotion

Malignant
Tumor

Progression

Proliferation
Mutation
Mutation
Cancer Gene Independence Invade & Spread

Stages of Cancer Formation

Anti-cancer Agents in Vegetables & Fruits

Inhibition of Initiation Stage of Cancer Formation
A) Block carcinogen activation
Flavonoids and isoflavonoids
Coumarins
Isothiocyanates in cruciferous vegetables
Organosulfur compounds in garlic & onions
B) Enhance carcinogen detoxification
Antioxidants in plants
Isothiocyanates in cruciferous vegetables
Organosulfur compounds in garlic & onions
C) Increase DNA repair
Polyphenols in green tea
Selenium

Latency Period, 20 years or more

Unspecialize
d
Cell

Initiated
Cell

Initiation

Benign
Tumor

Promotion

Malignant
Tumor

Progression

Proliferation
Mutation
Mutation
Cancer Gene Independence Invade & Spread

Stages of Cancer Formation

Anti-cancer Agents in Fruits & Vegetables

Inhibition of Promotion Stage of Cancer
Formation
A) Scavenge reactive oxygen species
Antioxidants in plants
B) Alter proliferation & differentiation
Phytoestrogens (+/-)
Retinoids

Phytoestrogens
- Estrogen-like chemicals in plants
- Soy products
High levels of phytoestrogens
Most studied phytoestrogens
- Studies of soy and breast cancer risk in
Asian population are conflicting
- Exposure before puberty may be necessary for
a protective effect
- Concern voiced because of estrogen-like effects
- Area of high interest

Whole Grains and Fiber

- A small decrease in breast cancer risk has
been associated with eating whole grains
- A small decrease in breast cancer risk
may be associated with dietary fiber
- 4 of 5 cohort no association
- 11 of 14 case-control small decrease
- Small decreases in tumors in animals
- Effects on circulating estrogens unclear

Meat and Fish

- Eating meat may be associated with increased
risk of breast cancer
- Women who eat red meat may have a higher
incidence of breast cancer
- Association of eating poultry and breast
cancer risk is unclear
- Most studies saw no association between
eating fish and breast cancer risk
- Studies examining methods of cooking and
doneness show a relationship to breast
cancer risk

Dairy Products
- Studies examining dairy product consumption
and breast cancer risk are conflicting
- Studies of childhood and adolescent
consumption of dairy products and
breast cancer risk are also conflicting
- Dairy products contain conjugated linoleic
acid (CLA) which decreases mammary tumor
formation in rats

Dietary Fat
Contradictory findings
- Positive association (increased risk)
Ecological studies, Animal studies

- Inconclusive association
Case-control studies of women

- No association
Cohort studies of women

Physical Activity
May be associated with decreased breast cancer
risk for women of all ages
Thought to possibly act by changing:
1)Menstrual activity
Exercise may increase age at menarche
2) Body characteristics
Exercise can decrease body fat
3) Hormone levels
Exercise may decrease estrogen levels

Smoking Tobacco
Effect of adult smoking (active & passive) is
unclear
Age beginning smoking may be important
Heavy smokers below age 20 have a
30% to 80% increase in breast cancer
risk
Cigarette smoke contains numerous
chemical which can initiate and promote
cancer
Breast fluids of smokers contain
chemicals from cigarette smoke

Alcohol Use
Adult use associated with risk (about 10%
increase for each drink per day)
All studies have reported impact of early age
alcohol use on breast cancer risk
About twice the risk of breast cancer for women
below 35 years
Alcohol use increases estrogen levels
Adequate folic acid (B vitamin) may decrease risk
in women who have more than 1 drink per day

Obesity
Associated with decreased premenopausal
breast cancer risk (25% decrease)
Interferes with regular menstrual cycling
Less proliferation in breast

Associated with increased postmenopausal

breast cancer risk (about 200% increase)
Increases estrogen exposure
Fat cells form estrogen from other hormones

Modifying the Stages of Cancer Formation

Decrease cells at risk
1) Childbirth
2) Diet?

Eliminate Initiated Cells

1) Childbirth?
2) Diet?
Initiated
Cell

Unspecialize
d
Cell

Initiation

Mutation
Cancer Gene
Decrease Initiation Process
1) Minimize Exposures
2) Childbirth
3) Diet
4) Avoid radiation exposure

Benign
Tumor

Promotion

Proliferation
Independence
Decrease Promotion Process
1) Decrease estrogenic exposures
2) Childbirth
3) Diet
4) Physical Activity

Prevention
Prevention

today refers mainly to lowering the

risk of disease.
Risk of most chronic diseases can't be totally
eliminated, it can still be significantly reduced.
If everyone in the US led a healthy lifestyle,
80% of the cases of heart disease and
diabetes could be avoided, as could 70% the
cases of stroke and over 50% of cancer.

How is Breast Cancer Treated?

Treatment depends on stage of cancer

More than one treatment may be used

Surgery

Radiation therapy

Chemotherapy

Hormone therapy

Targeted therapy

End