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Breast Cancer: Dr. Patty Tenofsky


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Dr. Patty Tenofsky of Via Christi Clinic spoke at the Via Christi Women's Connection luncheon about breast cancer statistics, screening for breast cancer, treatment options, radiation therapy and chemotherapy.

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Breast Cancer: Dr. Patty Tenofsky

  1. 1. Breast Cancer Updates Patty Tenofsky, MD FACS Women’s Connection October 11, 2011
  2. 2. Topics <ul><li>Breast Cancer Statistics </li></ul><ul><li>Screening for Breast Cancer </li></ul><ul><li>Treatment Options </li></ul><ul><li>Radiation Therapy </li></ul><ul><li>Chemotherapy </li></ul>
  3. 3. Statistics <ul><li>Incidence overall </li></ul><ul><ul><li>1 in 8 (about 13%) </li></ul></ul><ul><li>In 2008 </li></ul><ul><ul><li>182,460 new cases of invasive cancer and 67,770 of non-invasive breast cancer </li></ul></ul><ul><ul><li>About 40,000 died of breast cancer </li></ul></ul><ul><ul><ul><li>The death rates have been decreasing since 1990 </li></ul></ul></ul><ul><ul><ul><li>There are about 2.5 million women in the U.S. who have survived breast cancer </li></ul></ul></ul>
  4. 4. Statistics <ul><li>Only about 20-30% of women diagnosed have a family history — most are spontaneous </li></ul><ul><ul><li>A first degree relative with cancer, however, does double the risk </li></ul></ul><ul><li>5-10% of breast cancers are caused by gene mutations inherited from either mother or father (BRCA1 or 2 mutation) </li></ul><ul><ul><li>80% risk of breast cancer if you have this gene, usually at a younger age </li></ul></ul><ul><ul><li>20-40% risk of ovarian cancer </li></ul></ul>
  5. 5. Screening <ul><li>Self Exams </li></ul><ul><li>Physical Examination </li></ul><ul><li>Mammograms </li></ul><ul><li>MRI </li></ul><ul><li>Sonograms </li></ul>
  6. 6. Breast examination <ul><li>Self examination </li></ul><ul><ul><li>Studies have shown it does not decrease breast cancer deaths </li></ul></ul><ul><ul><li>However, all clinicians know that patients still find their own cancers — it is often a common manner of presentation </li></ul></ul><ul><li>Physician examination </li></ul><ul><ul><li>At least once a year </li></ul></ul><ul><ul><li>Least accurate method of diagnosis, but still important </li></ul></ul>
  7. 7. Mammograms <ul><li>10 year survival for patients with mammogram detected lesion and no mass: 95% </li></ul><ul><ul><li>Women 50-69 have decreased mortality with screening (30% fewer deaths) </li></ul></ul><ul><ul><li>Women 40-49 with less benefit, but most (not all) studies show 17-24% decreased mortality </li></ul></ul><ul><li>10-15% palpable masses are NOT seen on mammogram </li></ul><ul><ul><li>Physician and patient self exams must continue </li></ul></ul>
  8. 8. MRI <ul><li>Requires a special coil — c annot be done on any MRI machine </li></ul><ul><li>MRI: Because of blood supply, breast cancers become brighter more quickly and intensely than benign tissues on MR images after IV gadolinium (a type of dye) </li></ul><ul><ul><li>Patient lies face down; takes about 45 minutes </li></ul></ul><ul><ul><li>Low false negative rate (doesn’t miss too many cancers) </li></ul></ul><ul><li>Problems </li></ul><ul><ul><li>Very expensive test </li></ul></ul><ul><ul><li>High false positive rate (overcalls too many benign things as possible cancer leading to unnecessary biopsies) </li></ul></ul>
  9. 9. Ultrasound <ul><ul><li>Used to look at abnormalities seen on mammogram, MRI or on exam to clarify its characteristics </li></ul></ul><ul><ul><li>Not really a screening tool </li></ul></ul><ul><ul><li>The easiest method used for biopsies, therefore, if the abnormality can be seen on ultrasound, that is what will be used </li></ul></ul><ul><ul><li>Does not see calcifications well </li></ul></ul><ul><ul><li>Done both by surgeons and radiologists and is community dependent </li></ul></ul>
  10. 10. Breast biopsy <ul><ul><li>Minimally invasive with needle </li></ul></ul><ul><ul><ul><li>Helps plan surgery, simple, small scar </li></ul></ul></ul><ul><ul><ul><li>Minimal disruption of lymphatic channels which helps with checking the lymph nodes later on in the treatment stage </li></ul></ul></ul><ul><ul><li>Consensus Conference, 2005 (ACS) — breast biopsy is an outpatient procedure performed with a needle </li></ul></ul><ul><ul><li>Most biopsies can be done in a surgeon’s office or in the radiology department either with ultrasound or a mammogram machine to map the location </li></ul></ul>
  11. 11. Ultrasound biopsy <ul><li>Performed in either radiology department or in surgeon’s office </li></ul>
  12. 12. Stereotactic biopsy <ul><li>Prone table is used most often </li></ul>
  13. 13. <ul><ul><li>If the needle biopsy shows atypical cells, pre-cancer or cancer, the area must be removed. </li></ul></ul><ul><ul><li>A wire is inserted by radiology. </li></ul></ul><ul><ul><li>The surgeon follows the wire to the lesion. </li></ul></ul><ul><ul><li>A follow-up film is taken to make sure the lesion was removed appropriately. </li></ul></ul>Needle localized breast biopsy (lumpectomy)
  14. 14. Evaluation and treatment <ul><li>Surgical choice </li></ul><ul><ul><li>Breast conservation </li></ul></ul><ul><ul><li>Mastectomy with reconstruction </li></ul></ul><ul><ul><li>Mastectomy without reconstruction or delayed reconstruction </li></ul></ul><ul><li>Postoperative treatment </li></ul><ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Chemotherapy and herceptin </li></ul></ul><ul><ul><li>Hormonal therapy </li></ul></ul>
  15. 15. Lumpectomy
  16. 16. Mastectomy with or without reconstruction <ul><li>Women continue to receive a mastectomy between 30 and 70% of time </li></ul><ul><ul><li>Based on geographic location, age of patient, cancer fear and surgeon’s influence </li></ul></ul><ul><ul><li>Midwest patients have a higher incidence of mastectomy </li></ul></ul>
  17. 17. Mastectomy without reconstruction
  18. 18. Tissue expanders and implants <ul><li>Usually requires a staged approach </li></ul><ul><ul><li>Expander placed below the chest muscles at the time of mastectomy or delayed </li></ul></ul><ul><ul><li>Serial visits to plastic surgeon for expansion </li></ul></ul><ul><ul><li>Final procedure to place the implant (silicone or saline) </li></ul></ul><ul><li>Cosmetically not as good if radiation to be used, due to contractures </li></ul>
  19. 19. Latissimus flap and implant combination <ul><li>The muscle from the back may be rotated to create a breast </li></ul><ul><ul><li>Not usually large enough on its own </li></ul></ul><ul><ul><li>Implant is often added </li></ul></ul><ul><ul><li>Helps protect the implant </li></ul></ul>
  20. 20. Latissimus flap and implant Postoperative left mastectomy — left latissimus flap and implant Pre-operative view
  21. 21. Tram flap <ul><ul><li>More natural appearing — no implant needed </li></ul></ul><ul><ul><li>Does not interfere with healing, does not decrease survival or ability to find local recurrence </li></ul></ul><ul><ul><li>Much better if radiation has been used in the past </li></ul></ul><ul><ul><li>Longer, more difficult procedure </li></ul></ul>
  22. 22. Checking the lymph nodes <ul><ul><li>Cancer in the lymph nodes is the most important prognostic factor for a patient with breast cancer </li></ul></ul><ul><ul><li>Part of the surgical procedure is to check the nodes </li></ul></ul><ul><ul><li>5 year survival with surgery only: </li></ul></ul><ul><ul><ul><li>Node negative: 82% </li></ul></ul></ul><ul><ul><ul><li>1-3 positive nodes: 35% </li></ul></ul></ul><ul><ul><li>Methods to check the axilla: </li></ul></ul><ul><ul><ul><li>Sentinel node biopsy </li></ul></ul></ul><ul><ul><ul><li>Axillary node dissection </li></ul></ul></ul>
  23. 23. Sentinel node biopsy <ul><li>As cancer cells travel to the lymphatic channels, these cells lodge in the sentinel node(s) first. </li></ul><ul><ul><li>Travel to other nodes occurs as a secondary event </li></ul></ul><ul><ul><li>If the sentinel node is positive, the patient has the potential to have other positive nodes, and currently would receive a complete axillary node dissection in many cases </li></ul></ul><ul><ul><li>If the node is negative then no other treatment is required </li></ul></ul>Sentinel node (drum major) Other nodes (band members)
  24. 24. Axillary node dissection <ul><li>Still utilized: </li></ul><ul><ul><li>When sentinel node is positive on the day of surgery, but this is changing with lumpectomies </li></ul></ul><ul><ul><li>To determine the number of nodes that are involved and to remove the cancerous nodes </li></ul></ul><ul><li>Dreaded complication: lymphedema </li></ul>
  25. 25. Z-11 Trial <ul><li>In the 1990’s and 2000’s women were placed into a trial if their sentinel node contained cancer AND they were getting a lumpectomy </li></ul><ul><ul><li>1/2 of the patients received an axillary node dissection, chemo and radiation </li></ul></ul><ul><ul><li>1/2 the patients did NOT receive an axillary node dissection, but had chemo and radiation </li></ul></ul><ul><ul><li>NO difference in those two groups — therefore an axillary node dissection is probably not necessary in lumpectomy patients </li></ul></ul><ul><ul><li>Not certain if this can be applied to mastectomy patients </li></ul></ul><ul><ul><li>A huge step forward to decrease lymphedema rates </li></ul></ul>
  26. 26. Radiation for breast cancer <ul><li>Patients who will need radiation </li></ul><ul><ul><li>Breast conservation </li></ul></ul><ul><ul><li>Mastectomy if there is a tumor >5cm or there is 4 or more positive lymph nodes or margins are close </li></ul></ul><ul><ul><li>Inflammatory breast cancer </li></ul></ul><ul><li>Contraindications to radiation: </li></ul><ul><ul><li>Previous radiation (lymphoma patients) </li></ul></ul><ul><ul><li>Certain autoimmune diseases such as lupus & scleroderma </li></ul></ul><ul><li>Typically lasts for six weeks </li></ul>
  27. 27. Chemotherapy <ul><li>May be given before or after surgery </li></ul><ul><li>Most important prognostic factor in determination of treatment beyond surgery </li></ul><ul><ul><li>Lymph node status </li></ul></ul><ul><li>If lymph nodes are negative the most important factors: </li></ul><ul><ul><li>Tumor size </li></ul></ul><ul><ul><li>Tumor characteristics </li></ul></ul>
  28. 28. Chemotherapy <ul><li>Women who will get chemo: </li></ul><ul><ul><li>Premenopausal women with positive nodes </li></ul></ul><ul><ul><li>Postmenopausal women with positive nodes up to age 70 and then controversial </li></ul></ul><ul><ul><li>Pre- and postmenopausal women with negative nodes and increased risk factors: Based on the biology of the cancer </li></ul></ul><ul><ul><li>Women with very large tumors (locally advanced tumors) prior to surgery — chemo may shrink the cancer and allow breast preservation </li></ul></ul><ul><li>Women who probably won’t get chemo: </li></ul><ul><ul><li>Small tumors (<1cm) with positive hormone receptors and no other significant risk factors </li></ul></ul><ul><li>Oncotype Dx : </li></ul><ul><ul><li>A new DNA test on hormone positive tumors — it can help determine if a patient requires chemotherapy. </li></ul></ul>
  29. 29. Hormonal therapy and herceptin <ul><li>Hormonal therapy </li></ul><ul><ul><li>5 year treatment </li></ul></ul><ul><ul><li>Pre-menopausal: usually tamoxifen </li></ul></ul><ul><ul><li>Post-menopausal: usually an aromatase inhibitor (AI) such as arimidex </li></ul></ul><ul><ul><ul><li>Has been shown to be superior to tamoxifen </li></ul></ul></ul><ul><ul><ul><li>Not given to patients with ovarian function </li></ul></ul></ul><ul><li>Herceptin </li></ul><ul><ul><li>Given to most patients with Her 2/Neu positive tumors along with chemotherapy </li></ul></ul>
  30. 30. Conclusion <ul><li>Breast cancer is very common </li></ul><ul><li>Importance of screening </li></ul><ul><li>Biopsies are done with a small needle </li></ul><ul><li>Surgery: breast conservation or mastectomy </li></ul><ul><li>Chemotherapy and radiation </li></ul>