Transcript Update on Breast Care - Mithoefer Center for Rural Surgery

Update on Breast Care
M. Bernadette Ryan, M.D., FACS
Head, Section of Surgical Oncology
May 18, 2009
Outline
ANDI concept in benign breast disease
myatalgia
Breast imaging for screening & diagnosis
Breast Cancer
1/2009 update in NCCN guidelines
PBI
Oncotype Dx
ANDI
Aberrations of normal development and
involution
concept of benign disorders based on
pathogenesis
First published by Hughes et al. in 1987 in
Lancet
Embraced slowly in the USA
ANDI - 2
Bi-directional framework
Horizontal axis: main clinical presentation
normal - aberration - disease
Vertical axis: stages in development
early reproductive (15-25 years)
mature reproductive (25-40 years)
involution (35-55 years)
ANDI - 3
Normal Process
Aberration
Disease
Early
Reproductive
15-25 years
Lobular development
Stromal development
Nipple eversion
Fibroadenoma
Adolescent hyperplasia
Nipple inversion
Giant FA or multiple FAs
Gigantomastia
Subareolar abscess/
mammary duct fistula
Mature
Reproductive
25-40 years
Cyclic changes
Cyclic mastalgia
Nodularity
Ductal papilloma
Incapacitating mastalgia
Involution
35-55 years
Epithelia hyperplasia
of pregnancy
Lobular involution
microcysts
Duct involution
dilation
sclerosis
Epithelial turnover
Bloody nipple discharge
Macrocysts, adenosis,
sclerosing lesions
Ductal ectasia
Nipple inversion
Hyperplasia
Periductal mastitis/
abscess
Atypia
Non - ANDI
Fat necrosis
Lactational abscesses
Contributions of smoking and oro-nipple
contact in non-puerperal abscesses
True neoplasms: phyllodes tumor, tubular
adenoma, lipoma, etc.
Mondor’s disease, diabetic mastopathy, …
Mastalgia
Probably hormonally related
usually cyclic and ends with menopause
responds to hormone treatment
Many theories:
increased estrogen
decreased progesterone
increased prolactin
increased end-organ response
low prostaglandin E1 due to EFA deficiency
Mastalgia - 2
Cyclic or non-cyclic breast pain
rule out chest wall source in non-cyclic
rule out significant lesion with imaging
localized pain may be due to cancer, cyst,
sclerosing lesion
Treatment
Reassurance if mild
Reassurance and primrose oil if moderate
Add drugs if severe (interferes with lifestyle)
Mastalgia - 3
Cyclic Pain
Non-Cyclic
Primrose oil
44-58%
27%
Danazol
70-80%
30%
Tamoxifen
80-90%
56%
1000-1500 BID
200-400 mg QD
10 mg QD
Bromocriptine 47%
20%
Placebo
10-40%
2.5 mg BID
10-40%
Breast Imaging
Mammograms
Ultrasound
MRI
PET scans
Mammograms
Annual screening beginning at age 40
as young as 25 in high risk groups
upper limit not established
Digital mammogram may be better
especially in young women and older
women with dense breasts
Mobile units may increase compliance
Ultrasound
Initial diagnostic tool in women < 30-35
with symptoms or palpable findings
Adjunct to mammography
diagnostic w/u
biopsy
May be used with mammogram to screen
women at high risk or with dense breasts
no PRS showing survival benefit
MRI - screening
Screen high risk women
BRCA 1 or 2, TB53 or PTEN mutations
First degree relative with above & untested
Lifetime risk 20-25% by model based on FHx
Chest irradiation between ages 10 & 30
Role in women at lesser risk uncertain
LCIS, AH, prior breast cancer, 15-20% risk
Not recommended in average risk women
BRCAPRO
Free programs available
Need extensive family history
age of diagnosis of cancer as well as current
age or age of death of relatives
Calculates risk of harboring BrCa gene
and risk of developing breast & ovarian
cancer
BRCAPRO - 2
BRCAPRO - 3
BRCAPRO - 4
MRI - diagnostic
Define extent of disease before BCS
leads to higher mastectomy rate without
clear benefit in local control or survival
Define extent of disease before & after
neoadjuvant therapy
Look for additional primaries
Look for occult primary
Paget’s disease & isolated nodal metastases
PET scan
NCCN recommends against use in stage IIII disease
“Biopsy of equivocal or suspicious sites is
more likely to provide useful information”
Lobular cancer frequently PET negative
Not useful to stage axilla
overall role in breast cancer unclear
NCCN updates: DCIS
Minimum margin is still 1 mm
generally decreased failure rates with wider
margins up to 10 mm
post-excision mammogram if uncertainty
Recommends against sentinel node biopsy
reasonable for mastectomy
Excision alone in “low” risk disease
radiation reduces local failure by 50%
equivalent survival
NCCN: invasive cancer w/u
Genetic counseling if high risk
MRI optional
No PET or PET/CT
ER/PR and Her 2: use a reliable lab
Imaging to rule out metastases only if
symptomatic
may consider in locally advanced disease
NCCN - local treatment
Negative margin not defined
Focally + margin acceptable if no EIC
consider higher XRT boost to tumor bed
> 70, T1N0M0, ER/PR +
reasonable to treat with lumpectomy &
tamoxifen or an aromatase inhibitor
can be cN0 or pN0
NCCN - neoadjuvant
In Stage II & T3N1: only if pt wants BCS
Use in all other Stage III
Consider AI if post-menopausal & ER/PR
positive
cN+: confirm with needle biopsy
Level I & II dissection regardless of response
cN-: SNBx pre- or post-chemo
AxD if +
NCCN - Radiation
Radiation can be with or without a boost
boost: < 50, close margins, + nodes or LVI
PBI discouraged outside of a trial
Post-mastectomy XRT unchanged:
>/= 4 + nodes, >5 cm, margins < 1mm or +
consider in 1-3 nodes
Base XRT on initial clinical stage in
neoadjuvant patients
Partial Breast Irradiation
Low risk women
age > 45, tumor </= 3 cm, negative margins
& nodes (? DCIS)
Potential advantages
shorter treatment course
can give prior to chemotherapy
may improve access to BCS
? better cosmesis
Need PRTs to compare failure rates
PBI - 2
Treat tumor bed with 1 cm margins
Intra-op: single fraction
Post-op:
BID x 10 fractions with total dose 34-38.5 Gy
MammoSite and other balloons
after loading catheters
external beam with 3D conformal/IMRT
NCCN - adjuvant treatment
ER/PR + & Her 2 -: consider Oncotype
Still little data on chemo in women > 70
individualize considering co-morbidities
No prospective randomized data on use of
Herceptin in tumors < 1 cm & node but considered reasonable
Baseline & f/u DEXA scans if treat with AI
or if menopause induced by treatment
T1/2, ER/PR+, node -, her 2adjuvantonline
age, health, size, grade, nodes, ER/PR
odds of death or recurrence at 10 years
odds of benefit from adjuvant treatment
Oncotype Dx
21 gene test on paraffin blocks
recurrence score: correlates with 10-year
relapse in tamoxifen-treated patients and
with benefit from chemotherapy
Tailor X
PRT to determine value of Oncotype
Low RS (1-10): tamoxifen or AI
High RS (> 26): chemotherapy and
tamoxifen or AI
Intermediate RS (11-25): randomize
between 2 treatments above
Off study, 18-30 considered intermediate
about $3000 (some insurances cover test)
Future
Greater effort to tailor treatment to
individual to avoid toxicity without
jeopardizing survival
Pay for performance
accredited breast centers
adherence to national guidelines
volume of breast cases
Comments or questions?