detekdi dini ca. pd dr. indra-onko

8/10/2019 Detekdi Dini CA. Pd Dr. Indra-Onko

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BREAST CANCEREpidemiologi

Penyebab dan Faktor Resiko

Gejala dan Tanda

Stadium

Tindak Lanjut

Training 5 Hari Dokter-Bidan-Kader

Female Cancer Programme FKUI-RSCM/

YKI DKI dan Dinas Kesehatan DKI Jakarta

Indra Hidayah Siregar/

Ahmad Kurnia

Divisi Bedah Onkologi FKUI/RSCM Jakarta

Departemen Bedah FKUI/RSCM Jakarta



Ca mamae sin std IIIb



Ca mamae dex s td IIIb



Post m astectomy a/I Ca mamae dex std

IIIb- b ilateral std IV



In t roduct ion

• Most common female cancer

• Accounts for 32% of all female cancer

• 211,300 new cases yearly and rising

• 40,000 deaths yearly

US data

Indonesia ?



• Profil Kesehatan Indonesia 2008 :

– Urutan pertama (2004-2007)

– 8277 kasus (16,85%)

– Insidens di Indonesia : 36,2 per 100.000 pr

dengan angka kematian : 18,6 per 100.000

pr. (20.052 kasus). Data oleh GlobalBurden of Cancer, 2008.



• RSCM :

– Penelitian terhadap 300 pasien bedah,

(1989-1992) terbanyak : kanker payudaralanjut lokal (66%).

– 1998-2002 : 27,5%, tetapi stadium IV

meningkat (47,4%).

– US : KPLL < 5%



10 KANKER TERBANYAK DIINDONESIA

Number ICD Location Relative Frequency

1. 2. 3. 4. 5. 6. 7.

8. 9. 10.

180 174 173 147

183 196

154 171 193

Cervix Women's breast

Skin Nasopharynx

Unknown Ovaries

Lymphoid nodes

Rectum Soft tissue

Thyroid

18,41 %11,57 %8,24 %6,15 %5,16 %4,94 %4,91 %

4,42 %3,50 %3,38 %

Source: Bulletin of Pathology Based Cancer Registry, BRK-IAP, No. 4, 1989.



BREAST CANCERAge-speci fic incidence (per 100,000)

United

States

England

and Wales

Italy

France

Japan

Incidence rates

20 25 30 35 40 45 50 55 60 65 70 75 80 85+

24 29 34 39 44 49 54 59 64 69 74 79 84

420400

300

200

100

0

Age

Adapted from New Horizons in Cancer Management, SRI International, 1990.



BREAST CANCERRisk factors

Female

History of breast cancer

Family history of breast cancer, especially in

first-degree relatives : 1,8 x

Benign breast “cancer”/ atypical hyperplasia : 5 x

Early menarche : 1,7-3,4 x, late menopause : 1,5 x

Late first pregnancy/no pregnancy : 1,5-4 x

Exogenous estrogens

Radiation ( < 16 yo:100x, 20-29yo:6x, >30yo : -)

? Diet, alcohol



BREAST CANCERIncidence of major histo logic types

Percent of all Infiltrating Carcinomas

78%

9%4% 3% 5%

1%

Ductal Lobular Medullary Colloid Comedo Papillary

Adapted from McDivitt R et al, 1967.



Range ofDuctal Carcinoma in situ

15 I l l u s t r a t i o n ©

M a r y K .

B r y s o n



Detection



American Cancer Soc iety

• Skrining kanker payudara sedini

mungkin :

– Pr > 20 thn : sadari tiap bulan

– Pr > 20-40 thn : memeriksakan diri ke

dokter tiap 3 tahun

– Pr > 40 thn : memeriksakan diri ke doktertiap tahun

– Pr 35-40 thn : base line mammografi

– Pr > 50 thn : mammografi tiap tahun.



Waktu mamografi

Sebaiknya dikerjakan pada :

• Wanita usia diatas 35/40 tahun sebagaibaseline

• Wanita dengan faktor risiko tinggi

• 7-10 hari masa haid



Palpable mass

Thickening

Pain

Mass or pain

in the axilla

Nipple discharge

Nipple retraction

Edema or erythema

of the skin

BREAST CANCER/LOCAL MANIFESTATIONS

Signs and symptoms at presentat ion



Nipp le retracted



Nipp le dischrge



Peau d’orange

H i /



Hyperemis /

mast i tis carc inomatous



T 4

Ulkus

Peau d’Orange

Nipple retracted

Mass



Lymph nodes

Skin

Liver

Kidney

Brain

Pulmonary

Bone

BREAST CANCER/DISTANT MANIFESTATIONS

Signs and symptom s at presentat ion



Distan t Metastase

• Paru batuk, sesak,foto thorax

• Hati hepatomegali, USG hepar

• Tulang nyeri ketok,foto polos, bone scan

• Otak nyeri kepala hebat, scan



What Mammograms Show

Two of the most important mammographicindicators of breat cancers

– Masses

– Microcalcifications: Tiny flecks of calcium – likegrains of salt – in the soft tissue of the breastthat can sometimes indicate an early cancer.

29



Detection of Malignant Masses

Malignant masses have a more spiculated

appearance

30

malignant

benign



Mammogram – Difficult Case

31

• Heterogeneously dense breast

• Cancer can be difficult todetect with this type of

breast tissue

• The fibroglandular tissue(white areas) may hide thetumor

• The breasts of youngerwomen contain more glandsand ligaments resulting indense breast tissue



Mammogram – Easier Case

32

• With age, breast tissue

becomes fattier and hasfewer glands

• Cancer is relatively easyto detect in this type ofbreast tissue



BREAST CANCER

TNM stage grouping

Stage 0 Tis. N0 M0

Stage I T1 N0 M0

Stage IIA T0, T1 N1 M0

T2 N0 M0Stage IIB T2 N1 M0

T3 N0 M0

Stage IIIA T0, T1, T2 N2 M0

T3 N1, N2 M0Stage IIIB Any T N3 M0

T4 Any N M0

Stage IV Any T Any N M1



BREAST CANCERSurvival by s tage

Stage 0

Stage I

Stage IIA

Stage IIB

Stage IIIA

Stage IIIB

Stage IV

Percent surviving

100

80

60

40

20

0

1 2 3 4 5 6

Years after diagnosis



BREAST CANCER SCREENING PATH

Fine-needle aspiration

biopsy

Breast self-examination

Palpable

mass

(not cyst)

Diagnostic imaging

- mammogram

- ultrasound

- compression magnification filmNormal

Physical examination(yearly)

Screening mammogram(guidelines)

Suspicious Equivocal

Equivocal or

suspicious

Probably

benignCyst

Short-term

follow-upAspiration

Normal

– +



BREAST CANCER DIAGNOSIS PATH

Evaluation

for

biopsy

Cyst

aspiration

Fine-needle aspiration

biopsy

Needle

localization

Palpable

mass

Ductal

carcinoma

in situ

Invasive

cancer

Lobular

carcinoma

in situ

BenignInsufficientevaluation,rebiopsy

If persistent,

short-term

follow-up

with surgeon

Continued

appropriate

screening

Cyst Normal

Nonpalpable

mass

Treatment Path



BREAST CANCERTherapeut ic opt ions

Surgery

Radiotherapy

Chemotherapy

Hormonal therapy

Immunotherapy

New therapies

Supportive care



BREAST CANCERSurgical opt ions I

Local excision

mass

mass

Wide excision

…... Quadrantectomy



BREAST CANCERSurg ical op t ions II

Modified radical mastectomy Radical mastectomy

Incision

Excised area

mass mass

nodes

nodes

Excised area

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