Breast Cancer Treatment

1
Breast Cancer Treatment

• Three parts
• Local/regional therapy
• Systemic therapy
• Prevention
• Weigh risk/benefit ratio
• Timing
• Overall impact on survival

2
Local/regional therapy

• Surgery
• Halsted Radical Mastectomy
• Modified Radical Mastectomy ( Patey)
• Total Mastectomy
• Lumpectomy
• LumpAx
• Radiation reduces LR ½- ¾ and decreases deaths
  for ¼ recurrences prevented post mastectomy
• Whole breast
• 5 field
• Partial breast ( mammosite)

3
Systemic therapy

• Prognostic signs
• Size, nodes (sentinel vs regular), grade
• Predictive signs
• ER, PR, Ki 67, Her-2, etc.
• Two major types
• Cytotoxic reduces death rate about 1/3
• Antracyline based
• Taxane based
• Herceptin enhancement
• Hormonal
• Tamoxifen (SERM) reduces death rate about 1/4
• Aromatase Inhibitors reduces death rate about
  1/3
• Ovarian ablation, etc.

4
Prevention

• TAM reduces incidence of new cancers 49 if
  first ca was ER
• AIs reduce incidence of new cancers
  post-menopausally by 75-78 if first ca was ER
• PMastectomy reduces risk by 95

5
Case 1

• 47 y.o. WF 1.2 cm IDC detected on annual mammo
• MA 11
• PG 31
• Fam hx Mother _at_ 51
• No prior bx
• No other lesions in either breast on exam or
  imaging
• No c/o systemic disease
• Node negative on exam
• No grave signs on exam

• Local therapy options
• Lumpectomy
• Lumpectomy and Rad
• LumpAx Rad
• TM
• MRM
• HRM
• TM Rad
• MRM Rad
• HRM Rad

6
Case 1

• Path
• Margins negative
• Nodes negative
• ER PR
• Her 2
• Ki67 18

• Systemic Rx
• AC x 4
• AC x 4 and T x 4
• Tam x 5 yrs
• AI x 5 yrs
• ac
• bc
• dc

And what about prevention?
7
Case 1

• Which order to Rx?
• Surgery, radiation, chemo
• Radiation, chemo, surgery
• Chemo, radiation, surgery
• Chemo, surgery, radiation
• Doesnt make a difference

8
Case 2

• 27 y.o. WF 2.2 cm ILC detected on SBE
• MA 9
• PG none
• Fam hx M and 2 Sisters
• No prior bx
• No other lesions in either breast on exam or
  imaging
• No c/o systemic disease
• Node negative on exam
• No grave signs on exam

• Local therapy options
• Lumpectomy
• Lumpectomy and Rad
• LumpAx Rad
• TM
• MRM
• HRM
• TM Rad
• MRM Rad
• HRM Rad

9
Case 2

• Path
• Margins negative
• Nodes 1/6
• ER- PR-
• Her 2
• Ki67 48

• Systemic Rx
• AC x 4
• AC x 4 and T x 4
• Tam x 5 yrs
• AI x 5 yrs
• a herceptin
• b herceptin
• dc herceptin

And what about prevention?
10
Case 2

• Which order to Rx?
• Surgery, radiation, chemo
• Radiation, chemo, surgery
• Chemo, radiation, surgery
• Chemo, surgery, radiation
• Doesnt make a difference

11
Case 3

• 53 y.o. WF 0.6 cm IDC with DCIS detected on
  annual mammo
• MA 11
• PG 31
• Fam hx none
• No prior bx
• No other lesions in either breast on exam or
  imaging
• No c/o systemic disease
• Node negative on exam
• No grave signs on exam

• Local therapy options
• Lumpectomy
• Lumpectomy and Rad
• LumpAx Rad
• TM
• MRM
• HRM
• TM Rad
• MRM Rad
• HRM Rad

12
Case 3

• Path
• Margins negative
• Nodes negative
• ER PR
• Her 2
• Ki67 18

• Systemic Rx
• AC x 4
• AC x 4 and T x 4
• Tam x 5 yrs
• AI x 5 yrs
• ac
• bc
• dc

And what about prevention?
13
Case 3

• Which order to Rx?
• Surgery, radiation, chemo
• Radiation, chemo, surgery
• Chemo, radiation, surgery
• Chemo, surgery, radiation
• Doesnt make a difference

14
Case 4

• 83 y.o. WF with DCIS detected on annual mammo
• MA 11
• PG 22
• Fam hx none
• No prior bx
• No other lesions in either breast on exam or
  imaging
• No c/o systemic disease
• Node negative on exam
• No grave signs on exam

• Local therapy options
• Lumpectomy
• Lumpectomy and Rad
• LumpAx Rad
• TM
• MRM
• HRM
• TM Rad
• MRM Rad
• HRM Rad

15
Case 4

• Path
• Margins negative
• Nodes ?
• ER PR
• Her 2
• Ki67 18

• Systemic Rx
• AC x 4
• AC x 4 and T x 4
• Tam x 5 yrs
• AI x 5 yrs
• ac
• bc
• dc

And what about prevention?
16
Case 4

• Which order to Rx?
• Surgery, radiation, chemo
• Radiation, chemo, surgery
• Chemo, radiation, surgery
• Chemo, surgery, radiation
• Doesnt make a difference

17
Case 5

• 53 y.o. WF 6cm IDC with DCIS detected on PE
• MA 11
• PG 31
• Fam hx none
• No prior bx
• No other lesions in either breast on exam or
  imaging
• No c/o systemic disease
• Node positive on exam
• Erythema and edema on exam

• Local therapy options
• Lumpectomy
• Lumpectomy and Rad
• LumpAx Rad
• TM
• MRM
• HRM
• TM Rad
• MRM Rad
• HRM Rad

18
Case 5

• Path
• Margins close
• Nodes 5/23
• ER PR-
• Her 2
• Ki67 63

• Systemic Rx
• AC x 4
• AC x 4 and T x 4
• Tam x 5 yrs
• AI x 5 yrs
• ac
• bc
• dc

And what about prevention?
19
Case 5

• Which order to Rx?
• Surgery, radiation, chemo
• Radiation, chemo, surgery
• Chemo, radiation, surgery
• Chemo, surgery, radiation
• Doesnt make a difference

20
Case 6

• 53 y.o. WF with LCIS detected on excision of FA
• MA 11
• PG 31
• Fam hx none
• No prior bx
• No other lesions in either breast on exam or
  imaging
• No c/o systemic disease
• Node negative on exam
• No grave signs on exam

• Local therapy options
• Lumpectomy
• Lumpectomy and Rad
• LumpAx Rad
• TM
• MRM
• HRM
• TM Rad
• MRM Rad
• HRM Rad

21
Case 6

• Path
• Margins
• Nodes ?

• Systemic Rx
• AC x 4
• AC x 4 and T x 4
• Tam x 5 yrs
• AI x 5 yrs
• ac
• bc
• dc

And what about prevention?
22
Case 7

• 55 y.o. BF with ADH found on core bx
• MA 9
• PG 21
• Fam hx none
• No prior bx
• No other lesions in either breast on exam or
  imaging
• No c/o systemic disease
• Node negative on exam
• No grave signs on exam

• Local therapy options
• Lumpectomy
• Lumpectomy and Rad
• LumpAx Rad
• TM
• MRM
• HRM
• TM Rad
• MRM Rad
• HRM Rad

23
Case 7

• Path
• Margins
• Nodes ?

• Systemic Rx
• AC x 4
• AC x 4 and T x 4
• Tam x 5 yrs
• AI x 5 yrs
• ac
• bc
• dc

And what about prevention?