Breast Cancer Update
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  • 1. Update on Breast Care M. Bernadette Ryan, M.D., FACS Head, Section of Surgical Oncology May 18, 2009
  • 2. Outline
    • ANDI concept in benign breast disease
      • myatalgia
    • Breast imaging for screening & diagnosis
    • Breast Cancer
      • 1/2009 update in NCCN guidelines
      • PBI
      • Oncotype Dx
  • 3. 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
  • 4. 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)
  • 5. ANDI - 3
  • 6. 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, …
  • 7. 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
  • 8. 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)
  • 9. Mastalgia - 3
  • 10. Breast Imaging
    • Mammograms
    • Ultrasound
    • MRI
    • PET scans
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. BRCAPRO - 2
  • 16. BRCAPRO - 3
  • 17. BRCAPRO - 4
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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 +
  • 24. 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
  • 25. 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
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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)
  • 30. 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
  • 31. Comments or questions?