Early Detection of Breast Cancer

Department of Surgery, Division of Oncology, Faculty of Medicine of

Indonesian University/ Cipto Mangunkusumo Hospital
Kanker adalah sekelompok penyakit
yang ditandai oleh pertumbuhan yang
tidak terkendali dan penyebaran sel-sel
abnormal [...] yang dapat mengakibatkan
kematian “ (American Cancer Society, 2002)
 Etiology of Cancer

Faktor Eksternal Faktor Internal

Chemicals
Radiations Kegagalan repair
Ultraviolet Kesalahan
penyusunan kembali
Carcinogens

GEN
ABNORMAL
YANG MENETAP
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
Breast cancer represents about a quarter of all cancers reported
among women worldwide. But in parts of Africa and South America,
cervical cancer is a bigger problem (WHO)
 Introduction
• Breast cancer is the most common cancer
diagnosed and the second most commone
cause of cancer-related mortalities among
women in US
• In 2010 : 209,060 new cases were
diagnosed and nearly 40,230 BC-related
deaths occured
• Indonesia??
The Incidence of Breast Cancer in
Indonesia
• In Indonesia, breast cancer and cervical cancer are the top two
most common cancer
• Of about 20.000 new cases per year with incidence of cancer in
Indonesia 100 people/100.000 /year
• The incidence tend to increase gradually
 STADIUM KANKER
PAYUDARA
Stage 0 Tis. N0 M0
Stage I T1 N0 M0
Stage IIA T0, T1 N1 M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0, T1, T2 N2 M0
T3 N1, N2 M0
Stage IIIB Any T N3 M0
T4 Any N M0
Stage IV Any T Any N M1
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
The Incidence of Breast Cancer in
Indonesia
1. Various report have shown that most of breast cancer
patient in Indonesia seek medical treatment in a late
stage
2. More than 50% of cases were diagnosed in advanced
stage; locally advanced or distant metastase
Jakarta
Call Surabaya U.Pandang Rina Malig
Stage Call
Project Ramli (Sukarja) (Reupassa) Padang
Project II
I
Tis - - 1.3 % - - - -

I 2% 1.3 % 2.5 % 4.1 % 7.1 % 7,1% 1%

II 16 % 11.9 % 12.3 % 17.6 % 27.7 % 27.7% 12.8%

IIIa 23 % 17.7 % 26.3 % 55.9 % 49.2 % 49.2% 38.0%

IIIb 40 % 56.2 % 43.4 % - - - 31.0%

IV 19 % 11.9 % 14.3 % 19.6 % 15.8 % 15.8% 26.0%

Unclas-
- 0.8 % - 2.9 % - - -
sified
Adopted from Ramli M. Epidemiological Review of Breast Cancer in Indonesia, 1995
 Distribution Of Breast Cancer Patients
In RSCM (2008-2012)
1% 12.60%
3.40% 15% Stadium I
Stadium IIA
13.10%
Stadium IIB
Stadium IIIA
49.20% 5.60% Stadium IIIB
Stadium III C
Stadium IV

Picture 1. Distribution of locally

advanced breast tumor in cipto
mangunkusumo hospital (2008 – 2012)
 FAKTOR RESIKO
1. Haid pertama < 16 tahun
2. Menopause > 50 tahun
3. Tidak pernah menyusui anak
4. Melahirkan anak I : > 35 tahun
5. Pernah ada tumor jinak mammae
6. Usia > 30 tahun
7. Riwayat keluarga : (+)
8. Terapi hormon yang lama
9. Obesitas
10. Radiasi
 Faktor resiko

• Dapat dirubah • Tdk berubah

a. Riwayat kehamilan a. Riwayat keluarga
b. Oral kontrasepsi b. Genetik
c. Hormonal c. Siklus mensturasi
replacement d. Riwayat ca
d. Alkohol sebelumnya
e. Obesitas e. umur
f. menarche
 Gejala & Tanda
Kanker Payudara
 Adanya benjolan di ketiak

 Benjolan di payudara
 Penebalan
 Nyeri

 Cairan putting susu

 Retraksi putting/kulit

 Oedema kulit
Kanker Payudara
Skin dimpling
Nipple discharge
Paget`s disesase
Early detection is the best
protection
 HAMBATAN PROGRAM DETEKSI DINI

• PENGOBATAN ALTERNATIF
• PENDIDIKAN MASYARAKAT
• SDM TENAGA MEDIS
• PERALATAN
• SOSIAL EKONOMI
• KEADAAN GEOGRAFIS
KEUNTUNGAN DETEKSI DINI

• KEMUNGKINAN TDK KEMOTERAPI /RADIASI

• KEMUNGKINAN TDK DISEKSI KGB …..mengurangi limfedema
• DAPAT DILAKUKAN BCT SEHINGGA FUNGSI DAN ESTETIK
MASIH DAPAT DIPERTAHANKAN
• BILA TDK MEMENUHI SYARAT BCT DAPAT DILAKUKAN
SKIN SPARING MASTEKTOMI DAN REKONTRUKSI DENGAN
TEHNIK SUBUNIT ……… KOSMETIK BAIK
• PEMBIAYAAN
 Early Detection Methods
• Three-pronged approach

Screening
Mammography

Breast Clinical Breast

Self-Examination Examination

21
 Pemeriksaan Payudara
• Breast Self Examination (SADARI)
• Clinical Breast Examination (Pemeriksaan
Dokter)
• Pemeriksaan Penunjang: Mamografi
- ultrasonografi
- MRI, dll
BREAST SELF EXAMINATION
(SADARI)
• Tujuan: Mampu mengenal topografi

Bisa mengidentifiasi perubahan pada

payudara
• Dikombinasikan dengan CBE dan
Mamografi
• 2 Basic steps: Visual dan Taktil
 85% kelainan di payudara justru pertama
kali dikenali oleh penderita.
 Setiap selesai menstruasi pada setiap
bulan
• Not all lumps are cancers!
 CLINICAL BREAST
EXAMINATION

• Untuk pemeriksaan payudara yang secara

klinis sudah ada, yang dilakukan oleh
seorang bedah onkologi yang sudah
berpengalaman, bisa membedakan
sebuah tumor itu jinak atau ganas sebesar
80%.
• 4 Kategori : - massa yang dominan
- penebalan/ nodul yg asimetri
- nipple discharge
- perubahan kulit
Mammografi

•Clustered
microcalcification
•Masses
•Architectural distortion
and asymmetries
 BIRAD (Breast Imaging Reporting and
Data System)

1. Normal
2. Benign
3. Suspicious benign, follow up
4. Suspicious malignant, should be biopsy
5. Malignant, biopsy
 AMERICAN CANCER SOCIETY
1. Wanita >20th SADARI tiap bulan
2. Wanita 20-40th, tiap 3th periksa ke dokter
3. Wanita>40th, tiap th periksa ke dokter
4. Wanita 35-40th, base line mammografi
5. Wanita<50 th, konsultasi ke dokter utk
mammografi
6. Wanita >50th, tiap th mammografi
7. Wanita dg riwayat keluarga (+),
mammografi dini
Summary of American Cancer Society
Breast Cancer Screening Guidelines
• Annual mammogram starting at age 40
• Breast clinical exam age 20-40 every 3 years,
annual clinical exam beginning at age 40
• Optional breast self-exam beginning at age 20
• Women to be informed of the benefits and
harms of mammographic screening
• High-risk women: additional annual breast MRI
as adjunctive to mammography
Ultrasound
Biopsi

CHARUSHEELA ANDAZ, MD
Associate Director
Division of Breast Surgery
Treatment of breast cancer depends on:
– Size of the tumor (T)

– Invasive or in situ

– Lymphnode (N)

– Metastase (M)

STAGING
• Surgery
• Radiation therapy
• Chemotherapy
• Hormonal therapy
• Targetted therapy
 Beberapa tehnik pembedahan
pada keganasan payudara
• BCT
• Skin sparing mastektomi & nipple sparing
• Klasik mastektomi, MRM
• Semua tindakan diatas dengan rekontruksi segera/
ditunda
- LD
- TRAM
- SILIKON
- BCT dgn reduksi payudara
- graft lemak / dermal fat graft
 Definisi BCT
• Tumorektomi / lumpektomi
• Segmentektomi/quadrantektomi
• Diseksi aksila
• Radioterapi
 syarat
• Margin –
• Kosmetik Skin sparing
• radiasi Modified BCT
Breast conserving treatment(BCT)
Mastektomi Radikal Modifikasi
Rekonstruksi Payudara dengan
TRAM
• Radiation
- Adjuvant therapy
- Syarat ??
• Chemotherapy
- Neoadjuvant ( LABC)
- Adjuvant
• Hormonal therapy
- Hormonal Reseptor ( ER/PR)
• Targetted Therapy
- Her-2Neu