Breast Cancer Update

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

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

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 I-III 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?

Breast Cancer Update

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