Breast Cancer for the Community Medical School

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Breast Cancerfor theCommunity Medical School

• A Panel Discussion by
• Steven Birnbaum Marcia Browne Helen Corbett and
  Ping Zhou

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Tonights Objectives

• Tonight we are talking about the process and the
  choices we are making
• So our objectives are to teach you about
• Diagnosis
• Surgical treatment
• Chemotherapy
• Radiation therapy

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Diagnosis and Surgical Treatment

• Helen M. Corbett, MD
• Steven Birnbaum, MD

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Meeting Up with the Surgeon

• Our practice at the deNicola center is to have
  the patient meet with the surgeon as soon as
  there is a question on their mammogram
• Some women come on their own because of a concern
  on their exam
• Some women have a lump or unusual finding that
  their health care provider has found
• Some women have a strong family history

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Screening

• Strongly recommend Breast Self Exam
• One of few cancers you can find yourself

• Strongly recommend mammography
• Best screening exam for the general population

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Should You be Worried About Seeing a Surgeon?

• Abnormal mammogram still means only about 17 of
  the Category 4 Mammograms are proven to be
  cancerous
• Most common causes of lumps are benign
• We have circulated an approach for all the
  doctors associated with the deNicola center to
  evaluate breast issues to expedite an appropriate
  work up

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Initial Surgeon Visit

• History
• Looking for risk factors
• Looking for causes for the lump or mammographic
  finding
• Looking for symptoms

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Initial Visit

• Physical Exam
• Visible signs
• Palpable signs

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Assessment

• At times recommend additional imaging based on
  exam or based on risk
• Use the Gail Model risk assessment tool to
  identify High risk women
• Have an initial impression of size and extent of
  possible cancer to start considering surgical
  options
• Consider a future plan for genetic testing for
  women who meet criteria

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Possible Additional Imaging

• Usually an ultrasound for something that can be
  felt on physical exam
• A mammogram if the last one was 4 or more months
  ago
• An MRI for a woman with extremely dense breasts
  on Mammogram and/or a lifetime risk of greater
  than 20 for breast cancer

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Biopsy Recommendation

• In general agree with radiologist
• If there is a lump that is likely a fibroadenoma
• Can be watched, but
• Now recommend biopsy for most the first time they
  are noted
• Really a low threshold for recommending biopsy

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Category 3 Mammograms-- The Clinical Perspective

• The radiologists perspective is primarily based
  on the films
• Sometimes it is not technically possible to
  biopsy a mammographic finding
• The surgeons perspective depends more on other
  parts of the assessment
• The psychological stress of mammograms every 6
  months for 2 years is too much for some women
• Or the womans risk for breast cancer is too high

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Discuss Diagnosis

• Usually available within 72 hours
• Non cancerous usually plan a 6 month follow up
  exam
• Discuss any appropriate treatment
• Gray Area usually recommend a surgical wide
  excision to confirm diagnosis
• Risk of upgrade
• Cancer

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Breast Cancer Diagnosis

• Ductal
• Lobular
• Invasive
• Noninvasive
• Diagnosis of breast cancer depends on what it
  looks like under a microscope

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Caveat

• Almost anything related to breast cancer may be
  called more than one name
• Invasive infiltrating
• DCIS intraductal noninvasive ductal breast cancer

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Clinical Stage

• Based on estimated size of tumor
• Based on suspected or known presence in lymph
  nodes
• Based on presence elsewhere in the body
• Indicates course in treatment

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Breast Cancer Staging

• T refers to size of tumor
• N refers to status of lymph nodes
• M refers to presence of cancer elsewhere in the
  body
• These are then grouped into stages 0 to 4

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Breast Cancer Staging T0 No evidence of tumor Tis
In Situ cancer (lobular, intraductal, and Padgets
disease of nipple) No palpable tumor T1 Tumor 2
cm. or less in diameter T1a Tumor not fixed to
tissue, muscle T1b Tumor fixed to tissues T2
Tumor up to 5 cm. in diameter T2a Tumor not fixed
to tissue T2b Tumor fixed to tissue T3 Tumor
greater than 5 cm. in dia. T3a Tumor does not
extend to pectoral tissue or muscle T3b Tumor
fixed to tissue T4 Tumor of any size which
extends to chest wall or skin T4a Tumor fixed to
chest wall T4b Edema, ulceration of breast skin,
satellite nodes on same breast T4c Both a and b
above

• T stage

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Breast Cancer Staging

• T refers to size of tumor
• N refers to status of lymph nodes
• M refers to presence of cancer elsewhere in the
  body
• These are then grouped into stages 0 to 4

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• N stage

N0 No nodal involvement N1 Axillary nodal
involvement N2 Axillary nodal involvement with
nodes extended to one another or nearby
structures N3 Subclavicular nodal involvement or
edema of arm caused by lymphatic obstruction
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Breast Cancer Staging

• T refers to size of tumor
• N refers to status of lymph nodes
• M refers to presence of cancer elsewhere in the
  body
• These are then grouped into stages 0 to 4

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M0 No Metastasis M1 Metastasis present

• Metastasis
• Presence of Metastasis is Stage 4 cancer

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Stage 0 to 4

• Stage 0 Non invasive breast cancer
• Stage 1 Localized early breast cancer
• Stages 2 and 3 have several different options
• Stage 4 is distant spread
• Staging refers to an evaluation for more cancer

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Some Staging

• Personal practice is to obtain a preop MRI for
  most women
• Also obtain blood tests that look at whether
  there is likely a liver problem
• Chest X-ray
• If a woman does not have lymph node metastasis
  not indicated to do a more extensive search for
  distant disease

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Additional Biopsies

• MRI indicated other sites
• MRI or Ultrasound suggests lymph node involvement
• Based on screening tests

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Genetic testing

• Calculator to indicate risk for gene for breast
  cancer
• Usually covered by insurance if risk is gt10
• Insurance issue
• Not having the gene is not a guarantee that a
  currently unrecognized gene is not present
• If a family member is known to have a specific
  gene, relatives can have more specific test

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Surgical Planning

• The Straightforward Case
• Discussion of lumpectomy vs. mastectomy
• Statistically same survival for most women
• Some women do need a mastectomy
• Increasing numbers are requesting mastectomy
• Consideration for plastic surgery

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Lumpectomy (BCS)

• Usually partners with radiation
• Survival equivalence with mastectomy based on
  receiving radiation
• Does not affect need (or not) for chemotherapy
• Breast Conserving Surgery

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Lymph Node Surgery

• For invasive cancers need to remove a few lymph
  nodes to determine extent of disease called
  sentinel node dissection

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Lymph Node Surgery

• For invasive cancers need to remove a few lymph
  nodes to determine extent of disease called
  sentinel node dissection
• For known cancer in the lymph nodes need to
  remove all the lymph nodes in part of the axilla

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Intraoperative Lymph Node Evaluation

• Pathologist examines lymph nodes removed as part
  of sentinel node dissection
• If lymph nodes have cancer, remove the rest
  immediately

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Mastectomy

• Consideration for immediate reconstruction
• Consideration for delayed reconstruction
• Consideration for body habitus
• Basically the same surgery

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Lumpectomy Intraoperative Technique

• May need a wire to get me where I need to go
• Work with the radiologist and pathologist to try
  and get it all the first time
• National statistic is 60 of women who have a
  lumpectomy will require at least one more surgery
  to take more tissue

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Teamwork to Get it All

• Films available in the room
• Direct communication between the different
  doctors involved
• Need to have a rim of normal tissue around the
  cancer
• The pathologist brings the specimen in for the
  surgeon to review

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Oncoplastic Surgery Techniques

• Try to reshape the breast as much as possible to
  give a good cosmetic result
• Can make the radiation Oncologists work more
  difficult
• If margins are not clear next operation may
  require more tissue loss

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Complete Treatment Planning

• For the straightforward surgical case usually
  postoperative
• For the multiple issues case
• Tumor Board and a multidisciplinary care clinic
  provide a meeting of the minds earlier

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Test Results

• Pathology
• Radiology
• Oncotype DX
• Genetic
• PLUS PERSONAL HISTORY

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Treatment of Early Stage Breast Cancer
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Definitions

• Early Stage
• Stage I lt2 cm size axillary LN neg
• Stage II 2-5 cm size
• LN (movable ipsilateral)
• gt5 cm size with neg LN

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Definitions

• Locally advanced
• Extensive axillary LNsupraclavicularLN
• Extension to chest wall
• Inflammatory breast cancer
• Metastatic Stage IV

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Factors Affecting Treatment

• Lymph node involvement
• Size and extent of the tumor
• Histology
• Hormone receptors
• Her2 oncogene overexpression
• Age and/or menopausal status

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Adjuvant Therapy

• Systemic therapy given to patients with a risk of
  recurrence.
• Chemotherapy, endocrine therapy, Herceptin or a
  combination
• Administered after some or all local treatment
• Goal to decrease the chance of recurrence and
  improve survival

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Lymph node involvement

• Fluid from breast normally drains into LN in
  axilla
• LN status predicts likelihood breast cancer has
  spread and could grow in other organs
• If LN , twice as likely to have spread elsewhere
  and to recur.
• All patients with LN should receive adjuvant rx.

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Size and Extent of tumor

• Generally, larger tumors recur more often
• Early detection important

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Histology

• Invasive vs noninvasive (in situ)
• Tumor grade 1-3
• Grade 3 is more aggressive than grade 1

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Estrogen and Progesterone Receptors

• Patients with ER and PR tumors benefit from
  endocrine therapy -Tamoxifen (for premenopausal)
  or Aromatase Inhibitors (for postmenopausal)
• Patients with ER- and PR- tumors do not benefit
  from endocrine therapy and require chemotherapy

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Her-2 overexpression

• Human Epidermal growth factor Receptor 2
• 20 of breast cancer patients
• Associated with increase in recurrence and worse
  prognosis
• Treatment with Herceptin, a drug targeted towards
  the HER-2 improves survival.

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Adjuvant Treatment Regimen

• Chemotherapy
• Endocrine therapy
• Herceptin
• Combination

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Chemotherapy

• Multiple medications, usually given intravenously
• Administered in the office
• Schedule Once every 2 or 3 weeks
• 4-6 cycles
• Weekly MD/NP visits to check blood count and for
  other side effects

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Side Effects

• Many patients can work and do most of their
  normal activities
• Not meant to make you ill enough to be
  hospitalized
• Fatigue, hair loss, nausea, rare vomiting,
  lowering of blood counts
• Excellent medications available to decrease some
  side effects

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Endocrine therapy

• Must be ER or PR
• Oral medications
• 2 classes
• SERM Tamoxifen
• AI Femara, Arimidex, Aromasin (must be
  postmenopausal)
• Length of treatment at least 5 years

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Determining Factors for Endocrine Therapy

• Menopausal status
• Prior history of blood clots
• Osteoporosis
• Patient choice

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Herceptin

• Targets faulty genes that promote tumor growth.
• Only for Her-2 tumors
• Administered every 3 weeks for a year
• Immediate side effects minimal
• Possible cardiac side effects require monitoring
  of cardiac echo every 2-3 months

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Endocrine Therapy Side Effects

• Generally well tolerated
• Tamoxifen
• Hot flashes, - improve with time
• Weight gain - 25 gain 10 body wt
• Blood clots 1-2 depending on smoking
• Endometrial cancer 0.3
• Increases bone density

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Endocrine Therapy Side Effects

• Aromatase Inhibitors
• decreased bone density
• rare hot flashes
• joint pains in 20 of patients

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Breast Cancer Advances2009 Breast Cancer
SymposiumOcotober 6, 2009

• Regular mammograms decrease the risk of dying
  from breast cancer
• 3/4 of women dying of breast cancer had not
  had regular mammograms

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DCIS

• Women under 44 yo have almost double the risk of
  recurrence after lumpectomy and XRT
• Results suggest more aggressive treatment should
  be studied in this group

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Tumor Analysis

• New tool tissue microarray
• Analyzed tumor from node pts
• Goal to determine if adding taxol to treatment
  plan was helpful
• Sorted into 3 subtypes and found 2 subtype
  benefited from taxol and 1 (luminal A) did not

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Vitamin D Deficiency

• 69 women being treated for breast cancer
• More common
• Non-Caucasian women
• Women being treated for later stage BC
• Weekly high dose (50,000u) supplementation
  resulted in higher levels than low dose
  supplementation
• Talk with your doctor about Vit D supplements

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Goal for Treatment

• Tailor to the patient
• Decrease risk of recurrence
• Improve survival and quality of life

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Introduce Ping Zhou

• Radiation Oncologist

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Multidisciplinary Care Conference

• Along with the pathologist, Breast Health
  Coordinator, Cancer Care Coordinator who are not
  here tonight, we discuss research protocols and
  the best care for a given individual
• Bullet presentation will be put on screen
• STEVE please get films de-identified and ready
• MARCIA and PING READY TO discuss patient

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Case 1

• 40 yo nonsmoker
• Family history not known
• Gail risk 10.2 vs 12.4 for avg her age
• T2p, N1a, M0
• ER, PR, her2neu
• BRCA1
• Lumpectomy and axillary dissection

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Case 2

• 57 yo nonsmoker
• Premarin use
• 1 child at 31
• Gail risk 10.5 avg for her age 9.5
• Tis, N0, M0, high grade
• ER , PR -
• lumpectomy

• 57

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Case 3

• 64 yo smoker
• Prior breast surgery
• Gail risk 10.6 vs. avg for her age 8.1
• Lumpectomy with SLND
• T1, N0, M0, left Tis, N0, M0 right
• ER , PR , her2neu
• Pagets

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Final Recommendations

• Using Teamwork to identify staging
• Recommend adjuvant treatment
• Identify any concerns regarding treatment, follow
  up or missing elements in the staging

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• Piecing
• Together
• The Best Care for YOU