Topic-Driven Round Table on DCIS: Endocrine Therapy
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Facilitator Deb Hackenberry is joined by Dr. Deanna Attai, breast surgeon at UCLA Health, to discuss Endocrine Therapy as it pertains to DCIS.
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Topic-Driven Round Table on DCIS: Endocrine Therapy
- 1. DCIS 101 SHARE Cancer Support October 2019
- 3. What Is DCIS? • Malignant cell appearance • Non-obligate precursor • 15-50% progress to invasive cancer • ~20% upgrade rate • ~15% autopsies Wood JOP 2016 12;4;309-311 Cowell Mol Oncol 2013 7;5:859-869
- 4. • ~60,000 / year in U.S. • Typical presentation is calcifications on mgm • Occasionally presents as palpable mass 2009 NIH Consensus Conference https://consensus.nih.gov/2009/dcisstatement.htm
- 5. DCIS Incidence and Screening Mammography Vernig et al 2009 http://www.ncbi.nlm.nih.gov/books/NBK32570/
- 7. Estrogen / Progesterone (ER/PR) Receptors • Estrogen binds to the receptor (present inside the cell) and signals cell growth • ER+(positive): • Cancer cells have receptor, can be stimulated by estrogen • ER- (negative): • Cancer cells have lost the receptor, no response to estrogen Normal Cell ER+ Cancer Cell ER+ Cancer Cell ER- Estrogen Estrogen
- 8. Hormone Blockade • Normal breast cells can develop abnormal growth when exposed to estrogen • Growth of ER/PR+ cancer cells stimulated by estrogen • Reducing estrogen levels decreases risk of recurrence Cancer Cell ER+ Tamoxifen Estrogen Fat Cell Hormone precursors Aromatase EstrogenPremenopausal women: tamoxifen blocks ER receptor Postmenopausal women: estrogen made in fat cells Aromatase inhibitors block estrogen production
- 9. • Tamoxifen • Blocks the estrogen receptor • Pre- or post-menopausal • 5 years • Potential side effects: •Hot flashes •Vaginal discharge, ovarian cysts, irregular bleeding •Blood clots •Uterine cancer (~4%, average risk ~2%) • Aromatase Inhibitors •Anastrozole (Arimidex) •Letrozole (Femara) •Exemestane (Aromasin) • Blocks production of estrogen in the fat cells • Postmenopausal only • 5 years • Potential Side effects: •Hot flashes •Bone loss / osteoporosis •Joint pains
- 10. Why the Confusion? • Not one disease • Don’t agree on endpoint •Overall survival •Breast cancer specific survival •Invasive vs in-situ recurrence • Breast cancer specific survival approaches 100% regardless of treatment choice Moran December 2015 ASCO Post
- 11. How To Decide? •Treatment decisions require tradeoffs •What endpoint most important to patients •Can’t predict disease course
- 12. •Van Nuys Prognostic Index •Patient Prognostic Index •MSKCC Nomogram •Oncotype Dx DCIS •PreludeDx
- 13. • US Alliance COMET • UK LORIS • EORTC LORD Clinical Trials
- 14. DCISoptions.org
- 16. DCIS411.com
- 17. • Imaging • Core biopsy • Biomarkers • Tailored / precision therapy • No therapy for some • Intraductal therapy
Editor's Notes
- So clearly we have a range from indolent to aggressive behavior – DCIS is not one disease. It’s challenging because regardless of treatment, survival approaches 100%. It’s also challenging because we don’t all agree on the proper endpoint…
- Prospective trials
- Right now, we’re making assumptions based on the information we have – known biologic indicators such as grade and ER status, tumor size, patient age. But when we have a patient in front of us, we know we don’t have a crystal ball – we can’t predict if her indolent DCIS today will be the same in a few years. In the future, I expect that we will be acting on better biomarkers so we can get to that place of tailored or precision therapy for the individual patient