Transcript Dr Luce`s Breast Cancer Powerpoint

Breast Cancer Treatment:
An Evidence-based Review
Judith Luce, M.D.
Patient One
 Your
45 yo patient had her first screening
mammogram and was found to have
abnormal calcifications
 An ultrasound guided core biopsy was
performed and show DCIS (ductal
carcinoma in situ).
 What do you tell her about treatment?
 What about life expectancy?
Ductal Carcinoma In Situ: What is the Risk?
 DCIS
is not invasive cancer: however it
can recur in the breast as invasive cancer
about half the time
 Recurrence risk is dependent on


Age of the patient at diagnosis
Histology of the DCIS:
• Comedonecrosis, high grade are risk factors


Extent of disease: larger=higher risk
Extent of resection: negative margins
Age Affects DCIS Recurrence
Silverman, Buchanan Breast, 2003
Treatment Options for DCIS


Do nothing. Lifetime risk of invasive cancer ranges from
<10 to >50%. May be a choice for small low grade DCIS
in older pts
Remove all of the DCIS



Add radiation to the breast



Lumpectomy if feasible
Mastectomy if not: lowest odds of recurrence
Reduces recurrence risk by at least 50%
No real risk of lymphedema; other risk same
Add hormone therapy



Check for ER positivity
Reduces risk by about 20%
“Usual” duration five years
Patient Two
A
55 yo diabetic woman presents with a
small mass in her LUOQ. The FNA is
“ductal carcinoma”. You can’t feel any
axillary masses, and the mass itself is
about 4 cm. She’s frantic.
 Should you do a staging workup?
 What do you tell her about the initial
treatment?
 What do you tell her about prognosis?
Assessing the Risk of Invasive
Breast Cancer: Staging

Spread of breast cancer to adjacent lymph
nodes indicates high risk of distant spread of
cancer

If no further therapy, 50% or more will recur with
metastatic cancer

Size of tumor indicates risk of relapse: higher
“T” stage indicates higher risk
 Certain subtypes are higher risk:


Inflammatory breast cancer very high
Tubular, medullary carcinomas very low
Assessing the Risk of Diagnosed
Breast Cancer: Staging
 Staging


Removal of entire mass
Sampling of lymph nodes—sentinel node
 Higher



is performed surgically:
risk patients staged with
CT scans of abdomen and chest
Bone scan
Little role: brain scan, PET scan
Selection of Adjuvant Therapy for Invasive
Breast Cancer: a Risk-Benefit Equation

Prognostic factors: what is the risk of relapse?




Predictive factors: what will affect the choice of therapy?



Patient characteristics: age, menopause, race
Disease characteristics: size, histology, nodes
Biomarkers: ER/PR, growth fraction, Her2/neu, Oncotype
Patient characteristics: age, comorbid illness, performance
status
Biomarkers: ER/PR, Her2/neu, Oncotype, possibly growth
fraction
Risk/benefit: will the absolute magnitude of the benefit
exceed the long term risks?
Surgery for Invasive Breast Cancer

Lumpectomy +radiation therapy = mastectomy


Slight difference in local recurrence rate, esp younger women
Who is a lumpectomy candidate?
•
•
•
•
•
•

Woman wishes to preserve breast, willing to get radiation
Lump less than 5 cm diameter, mobile, not in center
Breast would look acceptable after resection
Margins must be clear of both invasive and in situ cancer
No other suspicious masses in breast
No inflammatory breast cancer
New developments: core biopsies, laser removal
• need to demonstrate completeness of excision
Breast Surgery: Sentinel Node Biopsy
for Staging of the Axillary Nodes

What is it? Radionuclide and dye-assisted
identification of the first node area, local bx
 If nodes negative and sampler proficient, then
predicts negative axillary dissection
 No need for axillary dissection if negative—spares
patient the risk of lymphedema
 No need to do this if mastectomy planned, if high
likelihood of positive nodes, if tail of breast involved, if
going to treat an older woman with adjuvant
Tamoxifen anyway
 Costlier, more time- and labor-intensive
Patient Two….
 She
comes back to ask your advice about
her surgical choices—mastectomy and
reconstruction versus lumpectomy. She
says she’s “scared” of radiation.
 What are the pros and cons of the two
approaches?
 What are her patient risk factors for one or
the other?
Breast Reconstruction
for Women with Mastectomy

Tissue reconstruction: use of autologous flaps for
reconstruction





Abdominal flaps “TRAM” flap—rectus abdominis
Latissimus dorsi flaps
Free flaps: DIEP flap—require vascular anastomosis
Can be done any time; Calif law requires insurance to cover
cost including contralateral reductions, mastopexy
Implants: best evidence suggests that silicone is
actually safe; still are problems with any implant


Puncture—forms intense inflammatory reaction and more
lumps if silicone, collapses if saline. Usually retropectoral,
so problems less vs augmentation
“Capsule” formation—alters shape, consistency
Radiation Therapy for
Primary Invasive Breast Cancer


As consolidation for lumpectomy patients
 Small effect on survival —1-2%?
 Affects breast outcome: 30+% risk of local failure
in younger women without XRT
 May not be necessary in oldest women: risk of
local failure with Tamoxifen, over 70, less than 5%
in studies
After mastectomy for high risk patients
 Large tumor, inflammatory, bulky nodes
 Controversial impact on survival (see figure)
Long Term Hormone Therapy Effects



Tamoxifen effects better researched
Tamoxifen does not cause menopause, but it
definitely increases the symptoms of menopause—
most common reason women stop
Serious risks due to agonist effects:




thrombosis (strongly age-related, includes stroke, MI, PE,
DVT)
endometrial Ca for postmenopausal women (2-3X increase
in risk)
Both risks disappear when drug is stopped—aromatase
inhibitors do not have these effects at all
Tamoxifen does protect bones: castration and
aromatase inhibitors do not
Patient Perspectives on Adjuvant
Therapy for Breast Cancer

Women need help with decision-making





Often find differing opinions among physicians
Are usually more satisfied if they have participated
Reliable sources of information are increasing
“Utility” is highly personal, variable, and persons
being asked in current studies are not representative
Diagnosis of breast cancer induces stress


Women recover with time
Women with premorbid problems are most likely to
need and benefit from support
Long Term Follow-up After Breast Cancer

Women who have had breast cancer are at lower risk
for new breast cancer event if treated systemically
 Women who have been treated with 5 years of
Tamoxifen have a reduced new opposite breast
cancer risk of about 40%; AI similar.
 Mammography annually, breast exam every 6-12
months is recommended by all experts
 Routine CT or bone scanning is NOT
recommended—no survival benefit
 Most experts use routine laboratory tests and
occasional chest x-rays as screening tests
 Most important aspect is careful history and physical
exam
Summing Up
Evidence-based therapies for DCIS and
invasive breast cancer:
Surgical excision—less is more
Radiation therapy—preserves breasts
Chemotherapy—younger, higher risk
Hormone therapy—ER+ all ages
Patient care includes education, support,
long term follow-up