Transcript 18 Feb 2016 - Multi Disciplinary Cancer

Multi Disciplinary Cancer
Management –Breast Cancer
Dr Masalu N. MD
Medical Oncologist
Breast Cancer Statistics II
Medical Oncologist
•Nearly 50% of diagnoses and 60% of breast
cancer deaths occur in underdeveloped
countries
•Breast cancer 5 year survival ~89% in US
(survival 75.2% in 1975), less than 40% in low
income countries
•Screening reduces deaths from breast cancer
in developed countries; impact of screening
unknown in low income countries
CA Cancer J Clin 2011, NCI SEER 2012, Lancet Oncology 2008
Breast Cancer Survival According
to Stage at Diagnosis
Medical Oncologist
Stage
0
I
II
5 year survival
100%
100%
93%
III
IV
72%
22%
*NCI seercancer.gov
Over 90% of US breast
cancer cases present
with localized or
regional disease
(nodes)*
Most breast cancer
cases in Tanzania
present with stage
IIIB or IV disease
Ductal Carcinoma In-Situ
(DCIS) of the Breast
Pathologist
• Clinical presentation: Incidental finding, mass,
abnormal mammogram
• Natural history: Limited studies but up to 30% of
women with partially resected lesions develop
invasive cancer at 6-10 years
• Treatment: Mastectomy (99% cure) vs. lumpectomy
+/- XRT
• Consider endocrine therapy for five years, especially
if tumor ER positive
Lobular Carcinoma In-Situ
Pathologist
• Clinical presentation: May lack mammographic signs,
incidental, more common in premenopausal women,
often multifocal or bilateral
• Natural history: Not a cancer but marker for increased
risk (subsequent carcinoma in opposite breast 50% of
the time and more often ductal histology)
• Risk of invasive cancer: ~1% annually
• Treatment: Cautious observation, rarely prophylactic
bilateral mastectomy
Interdisciplinary Team
Medical Oncologist
Spiritual counselor
Volunteers
Nurse
Family
Physician
Social
Worker
Patient
Psychologist
Community
Pharmacist
Physical
therapist
Hospice worker
Malignant cancer cells
can metastasize (spread
Normal cells know :
Neoplastic cells:
• When to grow
• How to differentiate
• When to stop growing
• When to die (apoptosis)
• Grow too much
• Do not differentiate
• Do not stop growing
• Do not die
Pathologic features important in
determining breast cancer treatment

Estrogen and Progesterone receptors are located in
the nucleus of the cell and are important factors in cell
growth

Estrogen and progesterone receptor status, HER2/neu, +/- Ki-67 status have documented clinical
usefulness as tumor markers and choice of therapy

Molecular profile (costly; limited access)
Breast Cancer Subtypes
Pathologist
Subtype
Pathology
Prevalence
Characteristics
Luminal A
ER and/or PR +
HER2Low Ki67
Grade 1-2
30-70%
-Best prognosis
-Fairly high survival rates
-Fairly low recurrence rates
Luminal B
-ER and/or PR +
-HER2+ or HER2- and
high Ki67
-Higher tumor grade
-Larger tumor size
-More often node+
10-20%
-Prognosis good, but
-Survival not as high as
luminal
Triple negative
(basal-like)
ER and PRHER2-
15-20%
-Aggressive
-Poorer prognosis in first 5
years
HER2 Type
ER and PRTypically HER2+
5-15%
-Younger age
-Outcome improved with
introduction of anti-HER2
agents
Treatment of cancer is multidisciplinary
Medical Oncologist
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Surgery
Radiation
Chemotherapy
Targeted Therapy
Gene Therapy
Tumor removal
DNA Damage
DNA Disruption or damage
Selective signal blocking
Replacement of gene function
FUTURE: Personalized therapy
“Identify which therapy will be more successful for each
patient”
Primary Consultation: MS
• MS is 52 years old
• She works as a manager
• She has had a mass in her left breast for one year
• No pain
• No nipple secretion
• No skin changes or
glands
Pregnancies 4
Deliveries
3
Menarche at age 12; last period at 50
Never had a breast biopsy
swollen
Family History
• Mother breast cancer at age 62 and a second primary
at age 68
• Sister breast cancer at age 57
• Maternal aunt breast cancer at age 59
• Maternal aunt ovarian cancer at age 68
• Maternal uncle colon cancer at age 65
• HBOC,BRCA1,BRCA2,LYNCH SYNDROME-HNPCC
• Vital signs: Temp 36.2
137/67
Pulse 89
Blood Pressure
• A large 6x8 cm movable breast mass, without skin
changes
• Axilla: Several enlarged lymph nodes
• Supraclavicular and cervical nodes: negative
• Liver feels normal
Should we order a
mammogram?- Radiologist
No need
B. Only for the affected breast
C. Only for the normal breast
D. Mammogram for both breasts prior to
biopsy
E. Not now, only after treatment
A.
10
Mediolateral
Medio-Lateral
Craniocaudal
Craneo-Caudal
Patient mammogram BIRAD 5
What should the primary
physician do? -Radiologist
Refer to surgeon for biopsy
B. Refer for chest x-ray and bone scan
C. Give antibiotics
D. Removal of breast without biopsy
E. Send home with pain medicines
A.
10
Surgeon’s checklist

Need to order mammogram if not already done

Need to confirm diagnosis with tissue biopsy
 Remember
to order receptors estrogen, progesterone,
Her2-neu and Ki-67
 Consider
staging tests for locally advanced disease
What kind of biopsy would you
do? Surgeon
A.
B.
C.
D.
E.
Core-needle biopsy
Fine-needle aspiration
Excisional biopsy
Punch biopsy
None of the above
10
Tissue –Sent to Pathologist
Information given:
-Breast “lump”
-Do receptors
(estrogen, progesterone,
Her2-neu, Ki-67)
Is this enough information for the pathologist?
Normal breast (skin, fat, breast tissue)
Hyperplasia with calcifications: Hematoxylin & Eosin
Ductal infiltrating carcinoma
Estrogen Receptor
Progesterone Receptor
Pathology Report:
-Infiltrating Ductal Carcinoma Grade III
some areas of in situ cancer
-Estrogen and progesterone receptors negative, HER2neu not amplified, Ki-67 25%
Breast Cancer Subtypes
Subtype
Pathology
Prevalence
Characteristics
Luminal A
ER and/or PR +
HER2Low Ki67
Grade 1-2
30-70%
-Best prognosis
-Fairly high survival rates
-Fairly low recurrence rates
Luminal B
-ER and/or PR +
-HER2+ or HER2- and
high Ki67
-Higher tumor grade
-Larger tumor size
-More often node+
10-20%
-Prognosis good, but
-Survival not as high as
luminal
Triple negative
(basal-like)
ER and PRHER2-
15-20%
-Aggressive
-Poorer prognosis in first 5
years
HER2 Type
ER and PRTypically HER2+
5-15%
-Younger age
-Outcome improved with
introduction of anti-HER2
agents
What investigations would you
do to complete the staging?Radiologist
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Laboratories?
CXR
Chest CT?
Abdominal ultrasound?
Abdominal CT scan?
CT scan brain?
Bone scan?
PET scan?
Please discuss
Patient Summary-Radiology

Mammogram right breast normal

6x8cm mass left breast – highly suspicious for
malignancy BIRAD 5

Pathology reports infiltrating ductal carcinoma, high
grade(III)

ER and PR negative, Her2-neu not amplified
(triple negative)

Staging studies negative
MS Case Summary-Medical Oncology

Mammogram right breast normal

6x8cm mass left breast – highly suspicious for
malignancy BIRAD 5

Pathology reports infiltrating ductal carcinoma, high
grade

ER, PR negative, Her2-neu not amplified (Triple
negative)

Staging studies negative

Clinical Stage: T3 N2 M0
What do you think should be done?
Medical Oncologist
Radical mastectomy
B. Modified radical mastectomy
C. Referral to medical oncology for
neoadjuvant treatment
D. Referral to radiation oncology for preoperative external beam radiation
E. Palliative care
A.
10
Discussion – case summary

Mammogram right breast normal

6x8cm mass left breast – highly suspicious for
malignancy BIRAD 5

Pathology reports infiltrating ductal carcinoma, high
grade

ER, PR negative, Her2-neu not amplified (Triple
negative)

Staging studies negative

Clinical Stage: T3 N2 M0 (Stage III)
Tumor Conference Treatment Plan:
Neoadjuvant treatment
Salvage mastectomy
External radiation therapy
Suppressive endocrine therapy ??
Follow up
Medical Oncologist’s thoughts, goals

Healthy 52 year old woman with locally advanced
breast cancer, triple negative, disease still seems
localized to the breast and axilla.

Neoadjuvant treatment (chemotherapy prior to surgery)
will reduce tumor size and allow a mastectomy or
perhaps a lumpectomy in selected cases.
In Fact post AC4 +T4 tumour size went down to 2x2
cm.
T1yNxMx.
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Medical Oncologist’s thoughts

MS does not qualify for post-operative endocrine
therapy (Tamoxifen or aromatase inhibitors) because as
her tumor was ER/PR negative
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She does not qualify for anti-HER2-neu therapy as her
tumor was HER2 negative.
Survival According to Treatment: Stage III
No. of
Patients
5-Year
Survival
Surgery only
2,453
36%
Radiation only
2,386
29%
Surgery plus radiation
4,249
33%
Chemotherapy, Surgery, and
Radiation
1,923
63%
Treatment
Giordiano SH. Oncologist. 2003;8:521-530.