Breast cancer video 2


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Breast cancer video 2

  1. 1. BREAST CANCER Robert Miller
  2. 2. Decisions that need to be made about treating breast cancer
  3. 3.
  4. 4. Treatment Decisions1. Surgery: mastectomy versus conservation (lumpectomy)2. Adjuvant Therapy: hormone therapy, chemotherapy, targeted therapy3. Radiation: whole breast or partial breast (balloon)
  5. 5. Treatment DecisionsThe woman should be assisted by a multi-disciplinary team, includinga surgeon, possibly a plastic surgeon, medical oncologist and aradiation oncologist
  6. 6. Deciding on Surgery Woman with modified radical mastectomy.Woman with lumpectomy. A pink highlighted area indicates tissue removed atA dark area indicates tumor mastectomyB light pink highlighted area B axillary lymph nodes: levels Iindicates tissue removed at C axillary lymph nodes: levels IIlumpectomy D axillary lymph nodes: levels III
  7. 7. Operable Breast Cancer: In Defense of Conservative Surgery CA: A Cancer Journal for Clinicians Volume 23:November/December 1973. George Crile Jr. Survival Comparisons Between the Cleveland Clinic (no mastectomies) with National Cancer Registry (mastectomies) Cleveland Clinic virtually abandoned radical mastectomies in 1957
  8. 8. Prospective Randomized Trials Comparing Conservation Surgery with Mastectomy in Early Stage Breast Cancer
  9. 9. Survival Comparisons Between Conservation Surgery (CS) plus Radiation (RT) versus Mastectomy
  10. 10. Mastectomy orLumpectomy10 year survival of112,154 women withstage I/II breast cancercomparing lumpectomy/ radiation withmastectomy.Radiation has a betterlong term survival thanmastectomy
  11. 11. Results of Randomized Trials Comparing ConservationSurgery (CS) With or Without PostOp Radiation (RT)
  12. 12. Reasons to Favor Mastectomy over Conservation/Radiation
  13. 13. Breast Conservation Lumpectomy (remove the cancer with a small rim of normal tissue, clear margins) Sentinel node biopsy will often be performed at the same time
  14. 14. Level 1 and 2 Nodes May be Removed,depending on the status of the sentinel node biopsies
  15. 15. At the time of the lumpectomy thesurgeon tries to remove the cancerwith a margin of normal breast tissuearound the mass X-ray image of the lumpectomy specimen
  16. 16. Deciding on the necessityand benefits of hormonetherapy or chemotherapy
  17. 17. Before radiation, a decision needs to be made about the need for systemic therapy (hormone therapy or chemotherapy)
  18. 18.
  19. 19. Genetic ProfilesMay show that some women with favorable breast cancer (estrogen + andnode -) may need more than just Tamoxifen / analyze the cancer for thepresence (expression of 21 breast cancer genes)
  20. 20. Genetic ProfilesMay show that some women withfavorable breast cancer (estrogen+ and node -) may need morethan just Tamoxifen 27% of women had a high risk gene profile and 30.5% relapsed after Tamoxifen and they may have done better with chemotherapy
  21. 21. Online Breast Cancer Calculators
  22. 22. For this elderly woman with a low risk cancer, the benefits from hormone therapy (0.3%) or chemotherapy (0.1%) would be very small and she would probably decide not to take either
  23. 23. Benefits of intensive chemotherapy in a young woman with high risk cancer For this young woman with high risk cancer, the benefits from chemotherapy would be very large (10 year survival would move from 33.5% to 51%) and she almost always would agree to it
  24. 24. Deciding on Radiation
  25. 25. Then a decision about the need for radiation and how large should the radiation target be
  26. 26. CT scan is obtained at the time of simulation CT images are then imported into the treatment planning computer. Note that at the time of the simulation the patient may receive 3 small tattoo marks
  27. 27. Computer generated anatomy images that will identify all theimportant structures to be sure the radiation covers the areaof breast cancer and limits the dose to other areas
  28. 28. Viewedfrom theside, theradiationstopsbeforehitting thelung
  29. 29. Typicaltechnique forexternal beam
  30. 30. Radiation beam skims over the surface ofthe chest wall, ribs and luring
  31. 31. Radiation Technique If the radiation does not go deep enough the cancer can grow back (the areas in the red) note: cases are from a textbook and not treated here at Wellspring
  32. 32. External Beam RadiationMonday through Friday for 5 weeks
  33. 33. After a lumpectomy the whole breast is radiated for about 5 weeks (the redRadiation box) and then a boost dose (5 – 7 treatments) isFields given to the lumpectomy site (blue circle)
  34. 34. Sometimes along with radiation to the breast, the highnodes in the neck (supraclavicular nodes) may betreated (the NCCN guidelines recommend these nodesbe treated if there was cancer in the axilla)
  35. 35. The whole breasttreated 26 to 28 timesThe lumpectomy siteis then treated 5 to 7times
  36. 36. Phase 1 External Beam Radiation (X-rays) lumpectomy Whole breast Lymph node treated with X-rays from side to side, and skims the surface of the lung or pleura
  37. 37. Phase 2 External Beam Radiation (electron beam) Electron beam is used to lumpectomy target straight on the area of the lumpectomy (and the radiation does not penetrate deeply)
  38. 38. Short Term Side Effects of BreastRadiation Generally the side effects of breast radiation do not become noticeable until the woman has received about 10 to 15 treatments, and then become somewhat more noticeable through the rest of the treatment. The most common side effects: •skin irritation - the skin that is radiated gets red, itchy and may blister (like a sun burn) may lose hair in arm pit (biafine, prutect, myaderm, aquaphor, silvadene, triamcinalone, Radiaderm) •breast or chest wall tenderness or mild pain •tiredness or fatigue (some women feel a little light- headed) •are swelling or edema
  39. 39. By 2 to 3 weeks the skin burn has healedup almost completely
  40. 40. Long Term Side Effects of Breast Radiation• Arm swelling or lymphedema is probably less than 3%• Lung inflammation (pneumonitis) is 5% or less• Risk of rib fracture is less than 3%• Risk of nerve damage (brachial plexopathy) < 1%• Radiation fibrosis to breast• Risk of causing a new cancer is less than 1%
  41. 41. BREAST CANCER Robert Miller