Current Treatment Options for Patients with Breast Cancer

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Current Treatment Options for Patients with
Breast Cancer

• Ian E. Smith
• Royal Marsden Hospital, London

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Improved Breast Cancer Survival
Peto et al Lancet 2000
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Local Treatment of Breast Cancer
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Local Treatment of Breast Cancer
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Local Treatment of Breast Cancer
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Local Treatment of Breast Cancer
Sentinel Node Biopsy
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Local Treatment of Breast Cancer
Large cancers Multifocal BRCA1/2?
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Local Treatment of Breast Cancer
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Radiotherapy
Always after conservative surgery Sometimes after
mastectomy
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Treatment of Breast Cancer
Bone Marrow Aspirate
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Adjuvant Medical TherapyGiven after Surgery for
Early Breast Cancer
The majority of patients with early breast cancer
used to relapse sooner or later however
intensive their local treatment
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Options for Adjuvant Therapy

• Endocrine Therapy ERve (75)
• Tamoxifen
• Aromatase Inhibitors
• Ovarian Ablation
• Chemotherapy - Higher risk
• Several options
• Herceptin - HER2 (20)

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Endocrine Therapy

• Only for ERve or PgRve (75)
• Low toxicity
• Long term 5years
• Aromatase Inhibitors slightly better than
  tamoxifen much more expensive
• Around 10 survival gain after 10 years

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Chemotherapy

• High toxicity
• Short term 3-6months
• Newer drugs slightly better (eg taxanes) much
  more expensive
• 1-25 survival gain after 10 years
• Careful selection of patients!

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Factors in Favour of Chemotherapy Benefit

• Node ve
• ER-ve
• Larger size of cancer gt2cm
• High Grade (esp III)
• Younger women

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Neoadjuvant Therapy before Surgery
Neoadjuvant therapy Tumour an in vivo measure
of response
Adjuvant therapy blind
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So Whats New?
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So Whats New?
Chemotherapy

• Taxol
• Navelbine
• Capecitabine
• Gemcitabine

Endocrine therapy

• cyclophosphamide
• methotrexate
• 5FU
• Adriamycin
• mitomycin C
• vinblastine
• mitoxantrone
• epirubicin
• cis/carboplatin
• Taxotere

Estrogens Androgens Progestogens tamoxifen toremif
ene Zoladex anastrozole letrozole exemestane Faslo
dex
Biologicals
Clodronate Pamidronate Zoledronate Herceptin Lapat
inib? Avastin?
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HER2 receptor and Herceptin
Growth factor
Blocking antibody
Binding site
Plasma membrane
Signal transduction to nucleus
Cytoplasm
Nucleus
CELL DIVISION
Gene activation
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Adjuvant Herceptin TrialsFirst Results
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Recurrence 4yrs
Recurrence 2yrs
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CT
CTH
CT
CTH
USA Trials
HERA Trial
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Should Treatment for BRCA1/2 Disease be any
Different?

• So far generally no but-
• BRCA1 usually ER-ve
• Sensitivity to chemotherapy may be different eg
  Carboplatin. Trial just started
• Prophylactic mastectomy

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Conclusions

• Mortality from breast cancer is falling
• An important reason is the widespread use of
  adjuvant medical therapy is addition to surgery
  RT
• Multidisciplinary teams required to plan
  treatment
• New targeted therapies are emerging Herceptin
  showing best breast cancer results ever