Tumor Board

1
Tumor Board

• Rummana Aslam, MD
• 9/23/2008

2

• RB 85 y/o woman referred for a suspicious
  mammographic finding 6 oclock position of 5 mm,
  asymmetry in left breast
• No family h/o breast cancer
• 4 children gravida-5, para-4 not breast fed her
  children
• No h/o birth control pills
• Not on any hormone pills
• Ambulates with a cane

3

• PMHx
• HTN, polycythemia, gets phlebotomy once a month
• Past surgical history
• Excision left breast cyst 1950
• Left hip surgery in 6/2007
• Medications
• Fosamax, ASA 325 mg, hydroxyurea, amlodipine,
  atenolol, HCTZ
• Allergies sulfa
• Transfusions none
• Social history
• Married with 4 children, retirted, non smoker,
  non drinker
• Family History
• No h/o breast cancer

4

• Review of systems
• Negative for 10 systems
• Physical examination
• Wt 138 Ht 5 ft 3 in 128/72 75 100 O2 saturation
• Head and neck, heart and lungs exam normal
• Right breast normal left breast nipple
  retracted, no eczema of nipple, slight thickening
  just below areola at 6 o clock, vague mass
  palpable, not definite and not fixed to the skin,
  nipple or muscle.
• Axillary lymph nodes not enlarged
• No other masses in the left breast
• Extremities show seborrheic keratoses

5

• Recommendation
• Needle localization and excision of mass along
  with cuff of 1 cm tissue around frozen section
  and if shows cancer to do a sentinal lymph node
  biopsy using lymphazurin
• Pathology
• Gross tumor size 1.0 cms
• Histological type infiltrating ductal carcinoma
• Negative margin
• Estrogen receptor negative progesterone receptor
  negative HER2-NEU negative
• Sentinal lymph node 1 and 2 no tumor seen

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Early Breast Cancer In Older Women

• Breast cancer is a disease of older women
• Incidence continues to rise with the growth and
  aging of the U.S population
• Elderly women frequently under-treated
• Poor representation in clinical breast cancer
  trials

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• Early breast cancer in the elderly Assessment
  and management considerations (Review)
• Albrand G. Drugs and aging. 2008
• Individualized oncogeriatric care plan based on
• Paients life expectancy
• Comorbidities
• Level of dependance
• Potential benefit-risk balance
• Impact of these considerations on therapeutic
  options and life expectancy

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• In elderly patient with breast cancer
• Standard primary therapy is surgical resection
• If unfit for surgery primary endocrine therapy
  for ER positive tumors
• Aromatase inhibitors not studied in elderly
  population
• Adjuvant chemotherapy trials have rarely included
  women 70 years
• Breast irradiation should be recommended for
  older women with a life expectancy of 5 years
• No follow up recommendations specifically for
  elderly patients after treatment of early breast
  cancer

9

• Surgery versus primary endocrine therapy for
  operable primary breast cancer in elderly women
  (70 years plus)
• Cochrane Database Syst Rev. 2006
• Randomized Trials 7 eligible trials, management
  of women aged 70 years or over with early breast
  cancer and who are fit for surgery
• Endocrine therapy was Tamoxifen
• Main Results data based on 869 deaths in 1571
  women

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• Overall survival no statistically significant
  difference
• Progression free survival Statistically
  significant difference favouring surgery with or
  without endocrine therapy
• Conclusions
• Primary endocrine therapy should only be offered
  to women with ER positive who are unfit and who
  refuse surgery
• Aromatase inhibitors as primary therapy in ER
  positive tumors trials are needed

11

• Update in Medical Oncology for Older Patients
  Focus on Breast Cancer Management of Early
  Breast Cancer
• Witherby S. M Muss Hyman. The Cancer Journal.
  2005
• Review of literature on early breast cancer in
  older women
• Role of surgical therapy, adjuvant hormonal
  therapy, chemotherapy, biological agents and
  radiation therapy

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• Breast cancer is not more indolent in older women
• When undertreated they have significantly worse
  outcomes
• Surgical resection of primary tumor for all
  elderly unless poor surgical candidates
• In node negative SLN dissection should be
  considered if this would change treatment
  decisions
• Breast irradiation for patients whose life span
  expected to be greater than 10 years
• In large tumors there maybe role for neoadjuvant
  endocrine therapy in hormone receptor positive
  patients and for chemotherapy in hormone receptor
  negative patients
• Not surgical candidates initial treatment with
  Tamoxifen or an AI alone ( insufficient data to
  recommend specific timing or the choice of AI)

13

• Adjuvant chemotherapy
• Efficacy decreases with age
• Efficacy should be calculated in the context of
  comorbidity and life expectancy
• Few elderly women with node-negative tumors will
  benefit from adjuvant chemotherapy
• Chemotherapy toxicity
• Older women experience more toxicity than younger
  couterparts although toxicity is not
  substantially higher in healthy older patients

14
Adjuvant chemotherapy in older women with
hormone receptor-negative breast cancer

• Adjuvant Chemotherapy and Survival in Older Women
  With Hormone Receptor-Negative Breast Cancer
  Assessing Outcome in a Population-Based,
  Observational Cohort
• Elkin et al. Journal of Clinical Oncology. 2006
• Population based sample obtained from cancer
  registry data
• Study population total of 1711 were women aged 66
  or older, included stage I, II, III breast
  cancers, and both estrogen receptor-negative and
  progesterone receptor-negative

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• Conclusions this analysis suggested a survival
  benefit from adjuvant chemotherapy in older women
  with HR-negative breast cancer. The benefit of
  chemotherapy is most pronounced in the patient
  most likely to be selected because of high- risk
  disease characteristics
• Chemotherapy use decreased dramatically with age
  from more than 52 of women aged 66-69 to
  approximately 5 of women age 85 or older

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• Unadjusted for any potential confounders,
  chemotherapy did not have a significant impact on
  overall survival
• Adjusted for the likelihood of receiving
  treatment chemotherapy was associated with a
  statistically significant 15 reduction in
  all-cause mortality
• Treatment effectiveness drawn from observational
  data are limited

17

• Propensity scores were used which may reduce
  selection bias but cannot replicate random
  treatment assignment of a clinical trial
• Other meta-analysis of randomized trials
• 13 reduction in all-cause mortality among women
  age 70 and older who received adjuvant
  chemotherapy
• Did not achieve statistical significance
• Small sample size precluded subgroup analysis by
  HR status

18

• A Randomized Trial of Adjuvant Chemotherapy with
  Standard Regimens, Cyclophosphamide,
  Methotrexate, and Fluorouracil (CMF) or
  Doxorubicin and Cyclophosphamide (AC) versus
  Capecitabine in Women 65 Years and Older With
  Early Stage Breast Cancer.
• Hyman B. Muss. 2008 ASCO meeting
• Randomized clinical trial in women 65 years or
  older with early stage breast cancer (tumor 1
  cm) stage T 1-4 disease, and any hormone receptor
  (HR) or nodal status, who were in reasonably good
  condition
• Both groups well balanced for demographic factors
  60 age 70-79 5 80 or older
• Goal was to see if an oral chemotherapeutic agent
  would be as effective as intravenous chemotherapy
  in this older group of patients

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• Between September 2001 and December 2006, 633
  patients were randomized to receive standard
  therapy with cyclophosphamide, methotrexate, and
  fluorouracil (CMF) for 6 cycles or doxorubicin
  with cyclophosphamide (AC) for 4 cycles, or to
  treatment with the single-agent oral capecitabine
  for 6 cycles. Selection of standard regimens was
  left to the physician's discretion
• Patients whose tumors were HR positive also
  received tamoxifen or aromatase inhibitors after
  chemotherapy

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• Results
• standard chemotherapy regimens were superior to
  capecitabine with respect to relapse-free
  survival as well as overall survival
• In an unplanned subset analysis the major benefit
  of of standard therapy (CMF or AC) was observed
  in HR-negative patients (30 of the study
  population)
• This subset of women on standard chemotherapy
  were two times more likely to have relapse free
  survival and were two times more likely to live
  compared with those treated with capecitabine

21

• Trials are now focusing on molecularly targeted
  agents e.g bevacizumab with chemotherapy in the
  adjuvant setting