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Guidelines for Management of Breast Cancer WHO Library Cataloguing in Publication Data EMRO Technical Publications Series 31 Guidelines for management of breast cancer WHO Library Cataloguing in Publication Data Guidelines for management of breast cancer/by WHO Regional Office for the Eastern Mediterranean p. (EMRO Technical Publications Series ; 31) 1. Breast neoplasms – Diagnosis 2. Breast neoplasms – Therapy 3. Breast – Cancer 4. Breast – Cancer – Guidelines I. Title II. WHO Regional Office for the Eastern Mediterranean III. Series ISBN : 978-92-9021-405-2 (NLM Classification: WP 870) ISSN : 1020-0428 © World Health Organization 2006 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Distribution and Sales, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 670 2535, fax: +202 670 2492; email: [email protected]). Requests for permission to reproduce WHO EMRO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to the Regional Adviser, Health and Biomedical Information, at the above address (fax: +202 276 5400; email [email protected] ). Cover design and layout by Ahmed Hassanein Printed by Fikra Advertising Agency Contents Foreword ..........................................................................................................5 Preface .............................................................................................................7 Acknowledgements .........................................................................................9 List of abbreviations .....................................................................................10 Chapter 1. Diagnosis of breast cancer ........................................................11 Clinical examination ..................................................................................11 Laboratory investigations ..........................................................................12 Pathological diagnosis ..............................................................................13 Clinical staging and risk assessment ........................................................13 Prognostic factors .....................................................................................15 Chapter 2. Treatment policy ..........................................................................16 Adjuvant systemic treatment .....................................................................16 Role of primary chemotherapy (neoadjuvant chemotherapy) in locally advanced breast cancer ............................................................................17 Follow-up ...................................................................................................22 Chapter 3. Management of metastatic disease ...........................................24 Staging of metastatic or recurrent breast cancer ......................................24 Local recurrence only ................................................................................24 Systemic dissemination ............................................................................24 Preferred chemotherapy regimens for recurrent or metastatic breast cancer .......................................................................................................25 Chapter 4. Surgical guidelines for breast cancer .......................................30 Surgical approach to the axilla including sentinel lymph node biopsy ......30 Surgical technique ....................................................................................31 Hospital stay ..............................................................................................32 Guidelines .................................................................................................32 Chapter 5. Management of special problems in breast cancer .................35 Chapter 6. Pathological handling of breast cancer excision specimens .40 General considerations .............................................................................40 Fine needle aspiration biopsy and core needle biopsy .............................41 Excision specimen for a palpable mass ....................................................41 Tissue submitted for histological examination ...........................................42 Mastectomy specimen ..............................................................................42 Tissue submitted for histological examination ...........................................42 Mammographically-directed excisions (wire localization specimens) .......43 Tissue submitted for histological examination ...........................................43 Frozen section diagnosis ..........................................................................44 Surgical pathology report of breast cancer specimens .............................44 Chapter 7. Radiotherapy guidelines for breast cancer ..............................47 Radiotherapy for ductal carcinoma in situ .................................................47 Criteria for breast conserving therapy .......................................................47 Post-mastectomy radiotherapy ..................................................................49 Radiotherapy after pre-operative systemic therapy ...................................51 Further reading ..............................................................................................52 Annex 1 Participants in the consultation on early detection and screening of breast cancer ...........................................................................55 Foreword In the Name of God, the Compassionate, the Merciful Cancer is an important factor in the global burden of disease. The estimated number of new cases each year is expected to rise from 10 million in 2002 to 15 million by 2025, with 60% of those cases occurring in developing countries. Breast cancer is the most common cancer in women in the Eastern Mediterranean Region and the leading cause of cancer mortality worldwide. There is geographic variation, with the standardized age- incidence rate being lower in developing than industrialized countries. Although the etiology of breast cancer is unknown, numerous risk factors may influence the development of this disease including genetic, hormonal, environmental, sociobiological and physiological factors. Over the past few decades, while the risk of developing breast cancer has increased in both industrialized and developing countries by 1%–2% annually, the death rate from breast cancer has fallen slightly. Researchers believe that lifestyle changes and advances in technology, especially in detection and therapeutic measures, are in part responsible for this decrease. Breast cancer does not strike an individual alone but the whole family unit. Despite considerable social changes, women continue to be the focus of family life. The impact of breast cancer is therefore profound on both the woman diagnosed with the disease and her family. Their fear and anxiety over the eventual outcome of the illness may manifest itself through behavioural changes. The high incidence and mortality rates of breast cancer, as well as the high cost of treatment and limited resources available, require that it should continue to be a focus of attention for public health authorities and policy-makers. The costs and benefits of fighting breast cancer, including the positive impact that early detection and screening can have, need to be carefully weighed against other competing health needs. Ministry of Health officials need to formulate and implement plans that will effectively address the burden of the disease, including setting policies on the early detection and screening of breast cancer. Health care providers should also be involved in discussion of the issue and in developing programmes for the management of the disease. I hope these guidelines will support everyone involved in the battle against breast cancer in the Eastern Mediterranean Region. Hussein A. Gezairy MD FRCS Regional Director for the Eastern Mediterranean Preface Breast cancer remains a common and frequently fatal disease, the most commonly diagnosed cancer in women and the second ranking cause of cancer death in the Eastern Mediterranean Region. More than 1.2 million women are diagnosed with breast cancer annually worldwide. In developed countries, most patients (> 80%) with breast cancer present with operable disease that can apparently be entirely resected surgically. About half of these patients
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