a brief overview about breast cancer management for general public and health care practitioners

1. Management of Ca
Breast
Oncologist’s Perspective
DR SADIA SADIQ
CONSULTANT CLINICAL ONCOLOGIST
INMOL

5. 5

6. Staging
T Stage
◦ Size
◦ Skin changes
◦ Deep structures
◦ Inflammatory changes
N Stage
◦ Clinical
◦ Location
◦ Fixicity
◦ Pathological
◦ Location
◦ Number
◦ Size
Metastasis

7. Histopathology : Primary
Histology
◦ Ductal/NST • Lobular • Mixed • Micropapillary • Metaplastic
◦ Pure tubular • Pure mucinous • Pure cribriform • Encapsulated or solid papillary carcinoma
Grade - Size –Location - Margins – LVSI – Number – Skin/Nipple involvement
ER status
PR status
HER2 status
Ki 67
BRCA 1/2

8. Histopathology : Nodes
FNAC : +/-
SLNB : Number – ENE –
ALND :
◦ Number
◦ ENE
◦ Size of largest deposit

9. Treatment
Local
◦ Surgery
◦ RT
Systemic
◦ Chemotherapy
◦ Hormonal Therapy
◦ Targeted Therapy

10. Chemotherapy
Neo-Adjuvant
Adjuvant
Palliative
Drugs
◦ Anthracyclins
◦ Cyclophosphamide
◦ Taxanes
◦ Platins
◦ Capecitabine
◦ Gemcitabine
◦ Vinorelbine

11. Neoadjuvant Chemotherapy
Candidates for Preoperative Systemic
Therapy
Inoperable breast cancer/T4
IBC
Bulky or matted cN2/N3 axillary nodes
In select patients with operable breast cancer it is preferred for:
◦ HER2-positive disease and TNBC, if ≥cT2 or ≥cN1
Large primary tumor relative to breast size
cN+ disease likely to become cN0 with preoperative systemic therapy

12. Non-candidates for Preoperative Systemic
Therapy
Patients with extensive in situ disease when extent of invasive carcinoma is not well-defined
Patients with a poorly delineated extent of tumor
Patients whose tumors are not palpable or clinically assessable

13. Known Benefits of Preoperative Systemic Therapy
Facilitates breast conservation
Can render inoperable tumors operable
Provides important prognostic information
Allows time for genetic testing
Allows time to plan breast reconstruction in patients electing mastectomy
Provides excellent research platform to test novel therapies and predictive biomarkers

14. Hormonal Therapy
SERMs
AIs
SERDs
CDK4/6 Inhibitors
mTOR Inhibitors

15. Targeted Therapy
Trastuzumab
Pertuzumab
TDM-1
Trastuzumab Deruxtecan
TKIs

16. Radiation Therapy
Indications
◦ T3/T4
◦ N+
◦ Margin +
◦ BCS

17. Radiation Therapy : Overview
RT APPOINTMENT
CT SIMULATION
CONTOURING
RT PLANNING
PLAN EVALUATION
RT DELIVERY
FOLLOW-UP
6/3/2023 17

18. CT SIMULATION
6/3/2023 18

19. VOLUMETRIC CONTOURING
CHEST WALL CTV
6/3/2023 19

20. INTACT BREAST CTV
6/3/2023 20

21. NODAL CTV
6/3/2023 21

22. Organs at Risk (0ARS)
6/3/2023 22

23. RT FIELDS
2 FEILDS
6/3/2023 23

24. PLAN EVALUATION
‘Dose Volume Histograms
6/3/2023 24

25. RT DELIVERY
6/3/2023 25

26. 6/3/2023 26

27. DCIS: Is RT necessary for DCIS?
Localized DCIS
Lumpectomy
N=403
19.4 %
Lumpectomy + RT
N=410
8.9 %
NSABP B-17
15 yr IBTR
27

28. T3-4 or N+
Mastectomy +
Chemo
27%
51%
Mastectomy +
Chemo + RT
4%
10%
POST MASTECTOMY RT
DANISH 2b
Pre menopausal
KEY POINTS
Improved LRC
and OS
5
1 – 3 nodes
> 4 nodes
28

29. T3-4 or N+
Mastectomy +
HT
27%
51%
Mastectomy +
HT + RT
4%
10%
POST MASTECTOMY RT
DANISH 2c
Post menopausal
KEY POINTS
Improved LRC
and OS
5
1 – 3 nodes
> 4 nodes
29

30. Can RT be omitted in early breast cancer?
T1N0 (< 1 cm) Carcinoma Breast
(1009)
After Lumpectomy
Tamoxifen
16%
RT + Tamoxifen
2%
RT + Placebo
9%
NSABP B-21
CONCLUSION
No difference in OS
8 year IBTR : RT + Tamoxifen better
30

31. Lumpectomy
> 65 years, Size < 3 cm, pN0, ER or PR or both +ve, Margin – ve
WBI + HT
IBRT 1 %
HT
IBRT 4 %
DO ELDERLY WOMEN NEED RT AFTER BCS
PRIME II
Kunkler Lancet 2015
KEY POINTS
No difference in OS
CLINICAL PEARL
RT can be omitted in > 70 years, ER+, T1N0 receiving hormonal treatment
8
31

32. T1-3N0-1 Margin clear
N = 2236
50Gy / 25#
7.4%
41.6Gy / 13#
6.3%
39Gy / 13#
8.8%
HYPOFRACTIONATION
UK START
A
KEY POINTS
No Difference in
10 year LRR
32

33. T1-3N0-1 Margin clear
N= 2215
50Gy / 25#
5.5%
40Gy / 15#
4.3%
HYPOFRACTIONATION
UK START
B
KEY POINTS
No Difference in 10
year LRR
breast shrinkage,
telangiectasia, and breast
edema were significantly less
in the 40 Gy group
2
33

34. BCS or Mastectomy
pT1-3 pN0 – 3a
N=4096
40 Gy in 15# 27 Gy in 5# 26 Gy in 5#
EXTREME HYPOFRACTIONATION
FAST FORWARD
Lancet 2020
KEY POINTS
26 Gy / 5# non
inferior at 5 years
CLINICAL PEARL
5 year IBTR 2.1 vs 1.7 vs 1.4 %
Higher tissue late effects at 27 Gy in 5# 34

35. Premeno
pT1-3,pN0 ER+
21 – Gene Recurrence Score
High > 26
Intermediate 15-
26
Low < 15
No benefit
IS THERE A BENEFIT WITH CHEMO IN pN0, ER+
ONCOTYPE DX
TAILORx
KEY POINTS
No benefit for low
score < 15
Benefit of chemo
esp 21-25 35

36. ER/PR +ve, HER 2 –ve, pN0/pN1 size < 5 cm, RRS 11 -
25
ET ET + CHEMO
ELDERLY WOMEN; CAN WE SPARE CHEMO
TAILOR X
Lancet 2013
KEY POINTS
No benefit of chemo
with RR < 25
CLINICAL PEARL
> 50 with hormone receptor positive, HER 2 –ve
36