So you have Breast Cancer: NOW WHAT???

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So you have Breast CancerNOW WHAT???

• Barbara A. Ward, MD
• Medical Director
• The Breast Center at Greenwich Hospital

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DO NOT PANIC!

• Almost everyone survives breast cancer, so why
  not you?
• Early detection DOES save lives!
• Why do you think there are so many breast cancer
  survivors at those walks?

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Educate Yourself

• Buy a book or go to a reliable website
• WWW.CANCER.ORG
• (American Cancer Society)
• WWW.CANCER.GOV
• (National Cancer Institute)

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Find Out The Facts and Get Organized

• Request a copy of your reports, especially your
  pathology report.
• The American Cancer Society provides a Patient
  Organization Tool, as do many Breast Centers.
• Are you at the right hospital and doctor?

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Quality Indicators

• National Accreditation Program for Breast Centers
  (NAPBC)
• Commission on Cancer (CoC)
• National Cancer Institute Sponsored Site
• Most University Hospitals
• Breast or Surgical Oncology Fellowship-Trained
  Surgeon

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Multi-disciplinary Care

• Breast Radiologist
• Breast Surgeon
• Reconstructive Surgeon
• Medical Oncologist
• Radiation Oncologist

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Other Team Members

• Nurse Navigator or Educator
• Pathologist
• Tumor Registrar
• Cancer Counselor
• Nutritionist
• Social Worker
• Physical Therapist

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Keep it Simple

• First decision typically involves surgery What
  type and Where?
• Dont feel bad about getting a second opinion,
  especially if a mastectomy is recommended

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Evolution of Surgical Practice

• Halsteds Radical Mastectomy
• Modified Radical Mastectomy
• 1985 Lumpectomy plus Radiation same survival
  rates
• 2006 Poor cosmetics so reassess surgical
  strategies

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Lumpectomy and Radiation

• Patient Selection Cancer is localized and can
  be removed with a margin of normal tissue..
  (Clear Margins)
• Surgeon feels that there is good to excellent
  cosmetic results.
• Patient willing and able to receive radiation

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Radiation Therapy

• Traditional treatment Whole breast radiation
  with boost.
• _at_ 32 treatments over 6 -7 weeks (minus weekends)
• Partial breast radiation possible over 1-2
  weeks vs. shortened course of RT to 3 wks
• May include Mammosite catheter placementrisk of
  infection and fibrosis.

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??????????????????????????

• Investigational vs. Cutting Edge
• Recommended in the context of a clinical trial.

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Nipple-Sparing Mastectomy

• Progression of Thought Pre-reconstruction era
  (_at_1960s) there was no attempt, but now there is
  renewed interest.
• Biologic considerations include
• SAFETY
• COSMESIS
• FUNCTION

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Recommendations

• Garcia-Etienne and Borgen (MSK)
• Negative lymph nodes
• Nipple Sparing Mastectomy for breast cancers less
  than 2 cm and more than 2.5 cm from nipple
• High-risk patients without cancer

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Recommendations

• Ward et al (GH) selective patients with low
  risk cancerssmall and away from the nipple, not
  including extensive DCIS.
• Question including BRCA ½ gene carriers (no
  specific data)
• High risk patients due to family history,
  anxiety, and LCIS, ADH

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Perforator Flap Reconstruction

• New option for reconstructive surgery
• BIG operation, but right for the right person
• Could involve the transfer of tissue from the
  abdomen or buttocks
• Seek a specialist in this technique

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TRAM
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Perforator Flaps
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DIEP Flap Technique
Skin and fat from the lower abdomen is surgically
transformed to form a new breast mound. This is
the most often performed procedure since excess
fat and skin are usually found in this area - the
end result is a "tummy tuck" - as well as a
reconstructed breast.
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DIEP Flap Technique
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DIEP Flap Technique
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Arterial Anastamosis
Double Opposing Clamps and Background are used
for arterial anastamoses
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Immediate DIEP Reconstruction
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Nipple Sparing Mastectomy
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Surgical Decisions

• Identify BRCA1/2 carriers for prophylactic
  surgery
• Higher rate of second breast cancer in same or
  opposite breast
• Sentinel lymph node surgery lowers the chance
  for lymphedema (arm swelling)

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What is my prognosis?

• Prognosis is based upon multiple facts from the
  pathology report
• Tumor Size and Grade
• Lymph Node Involvement
• Receptor Status
• Oncotype DX or Mammoprint Score

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Adjuvant Therapy

• Prognostic features from surgery, which includes
  removal of the sentinel node, will determine the
  need for chemotherapy
• Estrogen and Progesterone Receptors, Her-2 neu
  status, and size of tumor
• Oncotype DX Test, Mammoprint Test also factor
  into decision tree.

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Multidisciplinary Team

• Postoperative meeting with a MEDICAL ONCOLOGIST
• Presentation at Tumor Board
• Second Opinion always an option
• Decisions typically follow NCCN guidelines
• You are the final decision-maker

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New Targeted Therapies

• Herceptin is a new IV treatment targeted at a
  marker unique to cancer cells
• It is given over the course of a yearbut has
  resulted in amazing cures
• Avastin is also targeted at killing the blood
  vessels that feed cancer growth
• Results are more preliminary but hopeful

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Survivorship

• Buzz word for follow-up post treatment
• NEXT Step Program
• Nutrition/EXercise/Therapy
• Counseling and Support Groups

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What Can You Do?

• Lead by example regarding screening
• Quit smoking
• Buy the Breast Cancer Stamp
• Contribute to research efforts such as the
  American Cancer Society
• Participate in a Clinical Trial as a patient
• VOLUNTEER AT GILDAS CLUB!

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What else can you do?
                                                
                                             
                                                  
                                                  
                                                  
                                                  
                                                  
                                          

• Join the Army of Women

http//www.armyofwomen.org/
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(Remember why are there so many people walking?
Because so many are survivors!)

                                                                                      
Call for cancer information 1.800.ACS.2345