Breast Cancer Update

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Breast Cancer Update

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