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Early Stage Breast Cancer and Radiation Therapy
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Early Stage Breast Cancer and Radiation Therapy

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These slides are intended as an educational overview for newly diagnosed early stage breast cancer patients. My hope is that it can complement and enhance the doctor-patient relationship and shared ...

These slides are intended as an educational overview for newly diagnosed early stage breast cancer patients. My hope is that it can complement and enhance the doctor-patient relationship and shared decision making. I welcome any feedback on how to improve it.

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Early Stage Breast Cancer and Radiation Therapy Presentation Transcript

  • 1. Early Stage Breast Cancer Matthew Katz, MD October 2011
  • 2. Purpose
    • Improve understanding
      • Learn at your own pace
      • Understand medical terms
      • Make time with your doctor more valuable
    • Reduce anxiety
    • Help make an informed choice with your doctor
  • 3. Topics
    • Diagnosis
    • Staging
      • Imaging
      • Pathology: Biopsy and Surgical Findings
    • Role of Treatment for Breast and Lymph Nodes
      • Surgery
      • Medical/drug treatment
      • Radiation treatment
  • 4. Topics
    • Mastectomy or Breast Conserving Treatment
    • Radiation Treatment for the Breast
      • What to bring to your doctor
      • How it works
      • Treatment approach: whole vs. partial
      • Planning radiation treatment
      • Time commitment
      • Side effects during and after treatment
  • 5. Topics
    • 7. Treatment for the Nodes
      • Role of surgical evaluation
      • Role of radiation treatment
    • Follow-up After Treatment
    • Summary and More Resources
  • 6. Diagnosis
    • Most common cancer in women
    • In 2011…
      • ~ 57,000 will be diagnosed with non-invasive breast cancer
      • ~ 230,000 will be diagnosed with breast cancer
    • As of 2008, there were ~ 2.6 million alive after a breast cancer diagnosis
    Sources : http://1.usa.gov/SEERBreastStatFacts http://bit.ly/ACSBreastKeyStats
  • 7. Normal Breast
    • Normal breast ‘designed’ for milk
    • Female hormones normally cause growth of
      • Glands (lobules)
      • Ducts to nipple
    Source : http://bit.ly/ACSWhatIsBreastCancer
  • 8. Ductal carcinoma in situ (DCIS)
    • Tumor grows within walls of the duct
    • In situ = in ‘original position’
    • Should not have potential for spread
    Source : http://bit.ly/ACSWhatIsBreastCancer
  • 9. Invasive Ductal Carcinoma (Cancer)
    • Tumor grows through the wall of the duct
    • Involves surround fat
    • Potential for spread to lymph nodes or beyond
    Source : http://bit.ly/ACSWhatIsBreastCancer
  • 10. Invasive Lobular Carcinoma (Cancer)
    • Tumor grows through the wall of the lobule/gland
    • Involves surround fat
    • Potential for spread to lymph nodes or beyond
    • Tendency for multiple spots in the breast
    Source : http://bit.ly/ACSWhatIsBreastCancer
  • 11. Who Gets Breast Cancer?
    • Very common, many women have no risk factors
    • Increasing risk with age
    • Many possible risk factors
    • Only 5-10% are hereditary
    Source : http://bit.ly/ACSBreastRiskFactors
  • 12. Staging
    • Staging = determining if, or how far, cancer may have spread
    • Where is it in
      • Breast
      • Lymph nodes
      • Elsewhere in the body
  • 13. Staging System = AJCC
    • International organization updates
    • Features
    • TNM = T umor Size, skin changes
          • N ode Lymph node involvement
          • M etastasis Spread to bone, lung, other
    • 93% of invasive breast cancer has not gone beyond the nodes at diagnosis
    Sources: http://bit.ly/AJCCStaging http://1.usa.gov/SEERBreastStage http://bit.ly/ACSBreastStage
  • 14. What is ‘early’ breast cancer?
    • Non-invasive = Stage 0
    • Stage I and II
    • Stage III considered advanced
    • Stage IV has spread to bone, other areas
  • 15. Early Stage Breast Cancer No lymph nodes involved References: Solin et al, http://1.usa.gov/slIK15 Wapnir et al, http://1.usa.gov/ry1gBf Coburn et al, http://1.usa.gov/tGM1oo Adjuvant! Online v 8.0 Stage 10-year Breast Cancer Survival 0 (DCIS) 99% T1a/b N0 95+% T1c N0 90+% T2 N0 80%
  • 16. Early Stage Breast Cancer 1-3 Lymph Nodes Involved References: Adjuvant! Online v 8.0 Stage 10-year Breast Cancer Survival T1a/b N1 80-85% T1c N1 80% T2 N1 70%
  • 17. Imaging of the Breast
    • Mammogram
    • Ultrasound
    • MRI
    • All can be used for clinical staging (before surgery)
    • Helpful for treatment decisions
  • 18. Imaging of the lymph nodes
    • Mammography, US, MRI less helpful
    • Often requires biopsy to decide if the lymph nodes are involved
  • 19. Other Imaging
    • Chest x-ray
    • CT scan
    • Bone scan
    • Other
  • 20. What is a lymph node?
    • Part of immune system
    • Designed to help fight infection
    • Path of least resistance for cancer cells to move from breast
    Sources : http://bit.ly/WikipediaLNFunction http://1.usa.gov/NCIBreast
  • 21. Pathology
    • Study and diagnosis of disease
    • Often relies on looking at tissue
      • Under microscope
      • Special chemical stains
      • Sampling for gene mutations, other changes
  • 22. Breast Biopsy
    • Can give valuable information
      • Is it cancer?
      • What kind?
        • Cell type
        • Hormone receptors
        • HER2/neu status
    • Still only a sample
    • Rely more on findings at surgery
  • 23. Surgery
    • Breast conserving surgery
      • Goal = curative surgery with better cosmetic appearance
      • Often called lumpectomy, wide local excision or partial mastectomy
      • Became alternative to mastectomy in 1980s
    • Mastectomy
      • Complete removal of the breast
      • Has become less extensive since 1970s
  • 24. Pathology from Breast Surgery
    • Edges of breast tissue usually have ink placed
    • Under microscope, pathology doctor can ensure that no tumor at edge
    • Look at other features such as
      • hormone receptors ER/PR
      • HER2/neu [invasive cancer only]
  • 25. Surgery for Nodes
    • Increasingly, less is more
    • Sentinel lymph node biopsy – examines
    • node(s) most likely involved before
    • committing to axillary dissection
    • Sometimes more lymph nodes removed in axillary dissection [from underarm]
  • 26. Pathologic Stage
    • In early breast cancer, usually no treatment done before surgery
    • Surgical results give pathologic stage
      • Best estimate of how far the cancer spread
  • 27. Role of Different Treatments
    • Surgery
    • Medical treatment
      • Hormone therapy
      • Chemotherapy
      • Targeted therapy
    • Radiation treatment
  • 28. Surgery
    • Goal = cure
    • Different techniques
    • Mastectomy is historical standard
    • Breast conserving surgery usually an option for early stage breast cancer
  • 29. What do medical and radiation treatment do?
    • Treat what we don’t see
    • Medical = ‘think global’
    • Radiation = ‘act local’
  • 30. Medical Treatment
    • Hormone therapy
      • Block effects of your body’s hormones on cancer cell growth
    • Chemotherapy
      • Affect cancer cells and fast-growing normal cells
      • Various combinations
    • Both usually after surgery unless to help make lumpectomy possible
    Sources : http://1.usa.gov/NCIBreastHormoneTherapy http://1.usa.gov/NCIBreastChemo
  • 31. Medical Treatment
    • ‘ Targeted’ Therapy
      • Focuses treatment on distinctive features of cancer other than rapid growth
      • HER2/neu molecule  immune based treatment
  • 32. Radiation Treatment
    • Done after surgery and chemotherapy
    • Hormone therapy may be with or after radiation treatment
  • 33. Who Decides What Treatments I Need?
    • Ultimately, you decide
      • Get advice and information from doctors
      • Consider your values
      • Get support for an informed choice
    • Your Team :
    • Surgery = surgeon
    • Medical = medical oncologist
    • Radiation = radiation oncologist
  • 34. Mastectomy or Breast Conserving Surgery?
    • Mastectomy
      • Complete removal of the breast
      • Has become less extensive since 1970s
    • Breast conserving surgery (BCS)
      • Goal = curative surgery with better cosmetic appearance
      • Often requires radiation to be equally effective as mastectomy for cure
  • 35. Both are equally effective for long-term cancer survival
    • 20- year old study NSABP B-06 shows long-term survival is equal for mastectomy and lumpectomy with radiation
    • Have to be candidate for both for this data to apply
    • Decision based upon understanding differences between the two
    • Some decision aids available to help
    Sources : http://1.usa.gov/NSABPB06_20Yrs http://bit.ly/JCO_BreastDecisionBoard
  • 36. Differences in Early Stage Breast Cancer * Some patient with lymph node involvement may need radiation § Varies based upon several factors (age, tumor type + size, etc.) Factor Mastectomy BCS Keep my breast No Yes Avoid radiation Usually yes* Usually no § Less treatment time Depends how you define it ‘ Do everything’ Yes No ‘ Less (surgery) is more’ No Yes Recurs in breast Lowest Slightly higher Survival/Cure Equal
  • 37. Considerations in Making a Decision
    • Think about what you value more
      • Quality of Life : Breast preservation, sexuality, convenience, side effects of treatments
      • Tumor control : Reducing risk of recurrence, overall cure
    • Ask for specific information about risks/benefits from your doctors
    • Discuss your preferences with your social support and doctors
  • 38. Why do I see a radiation doctor?
    • Choice of surgery may dictate need for radiation treatment
    • May help with making informed choice
    • Ask your surgeon
  • 39. Surgery
    • Many different techniques
    • Ask your surgeon about treatment options, risks and benefits for you
  • 40. Radiation Treatment for the Breast
      • What to bring to your doctor
      • How it works
      • Treatment approach: whole vs. partial
      • Planning radiation treatment
      • Time commitment
      • Side effects during and after treatment
  • 41. What to Bring
    • Information about you and your medical history
    • Reports from
      • Surgeon, surgery
      • Mammogram, ultrasound, MRI (bring on disc too!)
      • Biopsy, surgical pathology reports
    • Friends/family if helpful
  • 42. What is radiation?
    • Energy from particles moving in space
    • Ionizing radiation = enough energy to affect
    • matter
    • X-ray = high energy light = photons
    • Other types: Electrons, Protons, Neutrons
    Source : http://bit.ly/IonizingRadiation
  • 43. How does radiation work?
    • Radiation goes through cancer cell
    • Damages critical cell machinery for growth
    • Different ways cells can die
    Source : http://bit.ly/ROWikibookRTDNA http://bit.ly/ColemanRadiationSensitivity http://bit.ly/ROWikibookCellDeath
  • 44. How do I know it worked?
    • In breast cancer, usually you don’t know for sure
    • Radiation usually used after surgery…
      • Nothing detectable
      • Treating possible cells left behind
      • No good test to show radiation worked
  • 45. ‘ No News Is Good News’
    • Can’t prove radiation worked, but time is the test
    • Each visit your doctors don’t find any evidence of recurrence, risk goes down
    • Self-breast exam, clinical exams and future imaging are important after treatment
  • 46. Why do radiation if you can’t tell it worked for me?
    • For each woman, it’s not possible to be sure, but…
    • Sort of like an insurance policy to reduce your risk of recurrence after lumpectomy
    • Ask your doctor what that risk may be
  • 47. Treatment approach: Whole vs. Partial
    • Standard treatment has been whole breast
      • Noninvasive treatment of breast instead of surgery
    • Many patients’ chance of recurrence is at surgical site, so can treatment be focused there?
  • 48. Why Partial?
    • Goal = treat less breast with equal or better:
      • cancer control
      • cosmetic appearance
      • normal tissue injury
      • Convenience
    • Reason = some patients have no cancer cells anywhere else except near surgical site
  • 49. Partial breast treatment
    • Different approaches (external and internal)
    • Typically 10 treatments in five days
      • Twice a day, separated by 6 hours
  • 50. Who is suitable for partial breast irradiation? Source : http://bit.ly/ASTRO-APBI-Consensus Factor Criterion Age 60+ years old BRCA 1/2 Not present Tumor 2 cm or less Margins Clear/negative by 2mm Vascular invasion No Type Invasive ductal, other favorable ER Status Positive Multifocal/centric No (unless <2 cm under microscope only) Nodes Negative or only on immunohistochemistry Node surgery Yes, either axillary sentinel node biopsy or axillary dissection
  • 51. Partial Breast Summary
    • Promising early results
    • Good option for selected patients with early breast cancer
    • Ask your radiation doctor about it as alternative to whole breast radiation
  • 52. Starting the Process: Simulation
    • Scheduled for CT scan to design treatments
    • No treatment, just planning
    • Like a virtual OR to plan noninvasive radiation treatment
    Source: http://bit.ly/GECTSim
  • 53. CT Simulation
    • Lie down
    • Temporary marks help with planning
    • Tattoos placed
      • More accurate daily
      • setup
      • Permanent ink
    • You can go, doctor works on planning
    Source: http://bit.ly/PhillipsCTSim
  • 54. Treatment Planning
    • Done with computer software
    • Makes sure breast +/- lymph nodes get treated
      • Limits normal tissue treated
        • Skin
        • Chest Wall (ribs, muscles)
        • Lung
        • Heart [Left breast]
        • Nerves [Shoulder area for nodes]
        • ? small amount to liver [right] or stomach [left]
  • 55. Treatment Planning: Whole Breast
    • Goal = treatment for breast
      • Especially surgical area
    • Treatment designed on computer after simulation
    • Approved plan then used for daily treatments
  • 56. Planning: Right Breast Image Credit: Phillips Medical Systems
  • 57. Planning: Blue beam Image Credit: Phillips Medical Systems
  • 58. Right Breast: Digital reconstructed x-ray
    • Used to make sure looks right
    • on treatment machine
  • 59. Getting Ready
    • After plan is complete, first visit is a ‘dry run’
      • Lie down in same position
      • Ensure tattoos help line up properly
      • Take x-rays to check setup
    • Before you even arrived, plan is approved by doctor and other members of treatment team
  • 60. Daily Time Commitment
    • Daily = ~ 15-20 minute appointments
    • Most is setup, treatment is quick
    • Usually one day a week longer to see doctor and nurse after treatment
    • Treatment time usually same every day, Monday to Friday
  • 61. How many treatments?
    • Traditionally, 30-33 treatments Monday -Friday (6 – 6.5 weeks)
    • May vary based upon newer research
    • As few as 16 treatments for selected patients
    Source : http://bit.ly/NEJMBreastHypo
  • 62. Side Effects Image Credit: Phillips Medical Systems
  • 63. Why do I get side effects?
    • Radiation interacts with normal cells and organs, not just cancer
    • Each dose creates low-grade injury
    • Can build over treatment
  • 64. Side effects ≅ Inflammation Source : http://bit.ly/WikiInflammationSigns Feature Why Redness Increased blood flow Warmth Increased blood flow Swelling More fluid + inflammatory cells to help with repair Pain/Irritation Chemicals released is tissue, nerve activity Altered organ function Ongoing injury
  • 65. Side Effects During Radiation or Weeks After Treatment
    • Common (25+% chance)
    • Skin Tanning, redness, irritation,
    • hair loss under arm
    • Breast Aches, mild throbbing pain, mild
    • swelling
    • Chest Tightness in chest/arm, occasional
    • muscle spasm
    • Energy Mild tiredness
  • 66. Side Effects During Radiation or Weeks After Treatment
    • Uncommon (~10-15%)
    • Skin Peeling like sunburn, rash
    • Breast More noticeable swelling
    • Pain Irritating enough to require
    • medicine stronger than ibuprofen
    • Energy Moderate tiredness
    • Appetite Mild decrease
  • 67. Side Effects During Breast Radiation or Weeks After Treatment
    • Rare (~1-5%)
    • Skin Require break in radiation for
    • healing
    • Energy Significant tiredness
    • Appetite Nausea
    • Other Decreased blood counts
  • 68. Managing Side Effects
    • See the nurse and doctor weekly
    • Can ask to see doctor any day of the week
    • Usually doesn’t interfere with ability to continue work and daily activities
  • 69. Managing Side Effects Side Effect Treatments Skin Hypoallergenic soap, moisturizers, lotions and sometimes pads Breast Ibuprofen (e.g. Advil), not likely to need prescription pain medicine Tiredness Pace yourself, prioritize what you need to do Rarely patients have break from treatment before completing it
  • 70. Side Effects After Breast Treatment (Months or Years)
    • Common (25+% chance)
    • Skin Occasional increased sensitivity,
    • mild dryness
    • Breast Mildly firmer, minor shrinkage
    • Pain Occasional discomfort in the
    • treated area
  • 71. Side Effects After Breast Treatment (Months or Years)
    • Uncommon (~10-15%)
    • Skin Mild permanent tan
    • Breast Moderate firmness, shrinkage
    • Chest Tightness in chest/arm, mild
    • decreased arm mobility
  • 72. Side Effects After Breast Treatment (Months or Years)
    • Rare (~1-5%)
    • Skin Fine red blood vessels develop
    • Breast Significant firmness, shrinkage,
    • tissue damage
    • Lung Inflammation and/or scarring
    • without long-term injury
    • Other Hand/arm swelling (lymphedema)
  • 73. Side Effects After Breast Treatment (Months or Years)
    • Very Rare (<1%)
    • Heart Inflammation or serious injury to
    • heart [left breast only]
    • Other Tumor caused by radiation
  • 74. Tips on Long-term Effects
    • Find out about stretching exercises to decrease/avoid chest tightness
    • Ask your doctor about lymphedema (arm swelling) prevention at time of surgery and radiation
    • Exercise, stop smoking to lessen any risk of heart problems
  • 75. Risk factors for radiation side effects
    • Radiation
      • Dose, location
    • Individual sensitivity
    • Other health conditions
      • Scleroderma, connective tissue disorders
      • Diabetes
    • Smoking
    • Other cancer treatments
      • Chemotherapy, hormone therapy, surgery
  • 76. Treatment for the Nodes
    • Surgery
    • Radiation
    • Current controversy in radiation for the nodes
  • 77. Surgery for Axillary Nodes
    • Old standard = dissection (10+ nodes)
    • If nodes not suspicious before surgery 
    • sentinel lymph node biopsy
    • Goal = deciding on need of chemotherapy, more than treatment
  • 78. Radiation for Nodes
    • Noninvasive, can be used for treating either axilla (underarm) or:
      • Supraclavicular
      • Internal mammary
    Source: http://bit.ly/Breast_orgNodes
  • 79. Follow-up After Treatment
    • Short term: 1-2 months after radiation
    • Long term:
      • Medical visits every 3-6 months for two years
      • Every 6 months for another three years, then annually
      • Followup mammogram +/- MRI
      • May alternate between surgeon, medical oncologist and radiation oncologist
      • primary care doctor also part of follow-up team
  • 80. Summary
    • Early stage breast cancer is a curable disease
    • Involves a team of doctors and medical staff
    • Two good approaches to breast cancer care
      • Mastectomy
      • Lumpectomy + radiation
    • Goal = maximize cure with treatments that have best side effect profile for you
  • 81. Summary
    • Think about what is important to you
      • Health concerns
      • Work
      • Family
      • Body image
      • Quality of life
    • Discuss with your doctors
  • 82. Summary
    • Radiation treatment is effective lowering risk of breast recurrence
    • Serious health risks from radiation are rare
    • Discuss with your doctors to learn more details personalized to your needs
  • 83. Resources For More Information Organization Website National Cancer Institute www.cancer.gov American Cancer Society www.cancer.org American Society of Radiation Oncology www.rtanswers.org American Society of Clinical Oncology www.cancer.net Association of Cancer Online Resources www.acor.org Breastcancer.org www.breastcancer.org LIVESTRONG www.livestrong.org