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Breast Cancer Awareness

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From Queens Library's expert-led panel, Cancer Awareness: What You Need to Know, featuring professionals from New York Hospital Queens, North Shore LIJ, the American Cancer Society, and the Leukemia …

From Queens Library's expert-led panel, Cancer Awareness: What You Need to Know, featuring professionals from New York Hospital Queens, North Shore LIJ, the American Cancer Society, and the Leukemia and Lymphoma Society

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  • 1. Breast Cancer in 2012 Jane Carleton, M.D. Monter Cancer Center North Shore-LIJ
  • 2. Breast Cancer in the U.S. 1 in 8 women in the U.S. will be diagnosed with breast cancer in their lifetime Hereditary vs. environmental causes Higher incidence of breast cancer in industrial areas, including most of the east coast, west coast and around the great lakes Is NYC or Long Island a hot spot?
  • 3. Hereditary Causes of Breast Cancer BRCA1 and BRCA2  Increased risk of breast and ovarian cancer  Only found in ~5% of breast cancer patients  More common in certain groups such as Ashkenazi Jewish population Only about 15% of breast cancer is clearly linked with a strong family history and possible inherited risk factor
  • 4. Screening for Breast CA Annual mammogram  Starting at 40 or 50?  Should it be every other year?  Current guidelines: start at 40 and every year Sonogram for patients with dense breast tissue or for additional evaluation (cyst vs nodule) MRI only in selected patients  Patients with BRCA mutation starting at 25  Patients newly diagnosed with breast cancer
  • 5. Evaluating a Nodule A needle biopsy is the preferred method to evaluate an abnormality found on mammogram or sonogram Needle biopsies are usually done by the radiologist as an outpatient and only require local anesthesia The majority of biopsies are benign Surgical biopsies should only be done when further evaluation or treatment is required
  • 6. Multidisciplinary Teams for Breast Cancer Treatment Radiologist Breast Surgeon Medical Oncologist Radiation Oncologist Genetics Counselor
  • 7. Surgery for Breast Cancer Lumpectomy vs mastectomy Sentinel lymph node evaluation  Only a few key lymph nodes removed Axillary lymph node dissection  Done when a sentinel lymph node is positive or if suspicious lymph nodes are seen or felt prior to surgery
  • 8. Reconstructive Surgery By law must be offered and covered by insurance for women having a mastectomy Reconstructive surgery is done by a plastic surgeon working with the breast surgeon Can be done at the same time as mastectomy Implants  With or without lattisimus muscle flap Autologous tissue recreating breasts  DIEP Flap  Tram Flap
  • 9. Pathology The biopsy and the surgery give us critical information about the tumor Is the tumor sensitive to hormones  Estrogen receptors  Progesterone receptors Her-2/neu  About 15-20% of breast cancer have this protein Triple Negative  ER negative, PR negative, Her-2/neu negative Lymph node status
  • 10. Breast Cancer Staging Stage 0: noninvasive cancer (DCIS) Stage I: tumor is <2 cm Stage II: tumor is larger than 2 cm and/or there are 1-3 lymph nodes involved Stage III: tumor is more extensive and/or more lymph nodes are involved Stage IV: the tumor has spread to distant lymph nodes or organs
  • 11. Why is Stage Important? Early stage breast cancer may only need hormonal treatment Lymph node involvement generally means chemotherapy should be given Larger tumors may need radiation Is the treatment goal curative or palliative  Stages 0-III goal is curative  Stage IV cancer is not curable but is treatable
  • 12. Radiology Imaging Studies to Determine Extent of Cancer Chest Xray Bone scan CT scan of chest, abdomen and pelvis CT or MRI of the brain Pet/CT scan
  • 13. Treatment for Breast Cancer Hormonal Therapy  Offered when tumor is hormone sensitive Chemotherapy  Important to individualize who really needs it Targeted Therapy  Her-2/neu positive breast cancer
  • 14. Hormonal Therapy Breast tumors have receptors for estrogen and/or progesterone 85% of the time Tamoxifen  Blocks the estrogen receptor  Works in both premenopausal and postmenopausal women and in men Aromatase inhibitors  Anastrazole (Arimidex)  Letrozole (Femara)  Exemestane (Aromasin)  These medicines lower estrogen levels in post- menopausal women
  • 15. Tamoxifen Used for 40 years Lowers chance of breast cancer recurrence by ~50% Generally well tolerated Side effects include hot flashes, changes in periods, vaginal dryness or discharge Risks include cataracts, blood clots (DVT/PE), stroke, endometrial cancer, uterine sarcoma
  • 16. Aromatase Inhibitors Available since the 1990s Arimidex was compared to Tamoxifen and shown to be slightly more effective with a better side effect profile (reported in 2002) No blood clots, uterine cancer or cataracts Increased risk of bone loss and fracture Increased risk of joint pain
  • 17. Chemotherapy & Hormonal Therapy Some patients will get only hormonal therapy (patients with smaller, lower risk breast cancers) Some patients will get only chemotherapy (estrogen/progesterone negative breast cancer) Many patients will receive both types of therapy to maximize the cure rate
  • 18. When Do We Use Chemotherapy? Tumor is larger than 1 cm (sometimes) Lymph nodes are involved The tumor appears aggressive  Poorly differentiated  Negative hormone receptors  Her-2/neu positive  High Ki-67 (marker of aggression) The Oncotype DX assay  Evaluates the tumor’s DNA  Used to determine when chemotherapy will be beneficial  Gives a score to predict risk of recurrence
  • 19. How We Choose Chemotherapy Chemotherapy has been tested in many clinical trials and certain drugs have come to be the mainstay of treatment, including adriamycin, cytoxan, paclitaxel (Taxol), docetaxel (Taxotere) Most breast cancer regimens use 2-3 drugs given over 4-6 cycles (doses) The characteristics of the cancer may determine the regimen recommended
  • 20. Standard Chemotherapy Regimens Taxotere and Cytoxan (4-6 cycles) Adriamycin and Cytoxan (four cycles) followed by Taxol (four cycles or 12 wks) Taxotere, Adriamycin and Cytoxan (6 cycles) CMF – Cytoxan, Methotrexate and 5-FU  An older less effective regimen
  • 21. Targeted Therapy: Her-2/neu Her-2/neu is a protein that some cancers have that can make the cancer more aggressive About 15-20% of breast cancers are considered Her-2/neu positive Trastuzumab (Herceptin) is a monoclonal antibody that binds to Her-2/neu on the outside of the cell Clinical studies showed that patients who were given Trastuzumab in addition to chemotherapy had a 50% improvement in their cure rate
  • 22. Who gets Trastuzumab? Trastuzumab (Herceptin) is indicated for patients who are strongly Her-2/neu positive A national clinical trial will study if patients who are more weakly positive will benefit from Trastuzumab as well (NSABP B-47) It may also benefit patients with DCIS when given with radiation (NSABP B-43)
  • 23. Other Her-2/neu Drugs Lapatinib (pill) that binds to Her-2/neu inside the cell Pertuzumab (Perjeta) FDA approved in 2012 to be used with Trastuzumab and Taxotere in metastatic breast cancer that has not previously been treated
  • 24. Other Targeted Therapies Bevacizumab (Avastin) T-DM1 (Trastuzumab linked to DM1, a chemotherapy agent) PARP inhibitors are being developed and are currently being studied in clinical trials. They may play an important role in “triple negative” breast cancer
  • 25. Bevacizumab Bevacizumab (Avastin) is a monoclonal antibody that binds to VEGF (vascular endothelial growth factor) The goal is anti-angiogenesis, or to block new blood vessel formation The drug is FDA approved for use in combination with chemotherapy for metastatic lung cancer and colon cancer and had been approved for metastatic breast cancer Breast cancer approval rescinded this year
  • 26. Bevacizumab in Breast Cancer FDA approval for breast cancer rescinded when studies showed that while there was some improvement in the response to chemotherapy there was no improvement in overall survival, raising the question of how effective the drug really is Further studies need to be done to establish the role of this drug ( e.g. NSABP B-46 for early stage breast cancer comparing TC vs. TAC vs. TC + Bev)
  • 27. Radiation Therapy Used for patients who have had a lumpectomy to improve local control Used for patients who have had a mastectomy if the tumor was large or there were many lymph nodes involved Used to treat a local recurrence Used in metastatic disease to decrease pain or symptoms in a particular spot
  • 28. Genetic Counseling Recommended for patients newly diagnosed with breast cancer if there is a greater than standard risk of having an inherited gene for breast cancer  Two or more close relatives with breast cancer  Any close female relative with ovarian cancer  Ashkenazi Jewish Not done routinely as expensive and chance of gene is low unless family history is strongly positive
  • 29. Follow Up Regular doctor appointments  Medical oncologist (2-4 times a year)  Surgical oncologist (1-2 times a year) Routine blood work Annual diagnostic mammogram Annual sonogram if dense breast tissue Annual breast MRI  Often ordered by the breast surgeons  Not accepted as a routine test on a national level
  • 30. Where Do We Stand? 85% of all women who are diagnosed with breast cancer will die from a non cancer related cause The incidence of breast cancer has dropped in the last ten years (especially since estrogen therapy for postmenopausal women no longer being offered as standard therapy for years) More breast cancer is being detected in earlier stages, improving the chance of cure New drugs continue to be developed which will further improve our success in treating breast cancer