Breast Cancer Treatment

• Three parts– Local/regional therapy– Systemic therapy– Prevention

• Weigh risk/benefit ratio

• Timing

• Overall impact on survival

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)

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.

Prevention

• TAM – reduces incidence of new cancers 49% if first ca was ER+

• AI’s – reduce incidence of new cancers post-menopausally by 75-78% if first ca was ER+

• PMastectomy reduces risk by > 95%

Case 1

• 47 y.o. WF 1.2 cm IDC detected on annual mammo– MA 11– PG 31– Fam hx – Mother @ 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 optionsa) Lumpectomy

b) Lumpectomy and Rad

c) LumpAx Rad

d) TM

e) MRM

f) HRM

g) TM Rad

h) MRM Rad

i) HRM Rad

Case 1

• Path– Margins negative– Nodes negative– ER+ PR+– Her 2 –– Ki67 18%

• Systemic Rx a) AC x 4

b) AC x 4 and T x 4

c) Tam x 5 yrs

d) AI x 5 yrs

e) a+c

f) b+c

g) d+c

And what about prevention?

Case 1

• Which order to Rx?a) Surgery, radiation, chemo

b) Radiation, chemo, surgery

c) Chemo, radiation, surgery

d) Chemo, surgery, radiation

e) Doesn’t make a difference

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 optionsa) Lumpectomy

b) Lumpectomy and Rad

c) LumpAx Rad

d) TM

e) MRM

f) HRM

g) TM Rad

h) MRM Rad

i) HRM Rad

Case 2

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

• Systemic Rx a) AC x 4

b) AC x 4 and T x 4

c) Tam x 5 yrs

d) AI x 5 yrs

e) a+ herceptin

f) b+ herceptin

g) d+c + herceptin

And what about prevention?

Case 2

• Which order to Rx?a) Surgery, radiation, chemo

b) Radiation, chemo, surgery

c) Chemo, radiation, surgery

d) Chemo, surgery, radiation

e) Doesn’t make a difference

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 optionsa) Lumpectomy

b) Lumpectomy and Rad

c) LumpAx Rad

d) TM

e) MRM

f) HRM

g) TM Rad

h) MRM Rad

i) HRM Rad

Case 3

• Path– Margins negative– Nodes negative– ER+ PR+– Her 2 –– Ki67 18%

• Systemic Rx a) AC x 4

b) AC x 4 and T x 4

c) Tam x 5 yrs

d) AI x 5 yrs

e) a+c

f) b+c

g) d+c

And what about prevention?

Case 3

• Which order to Rx?a) Surgery, radiation, chemo

b) Radiation, chemo, surgery

c) Chemo, radiation, surgery

d) Chemo, surgery, radiation

e) Doesn’t make a difference

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 optionsa) Lumpectomy

b) Lumpectomy and Rad

c) LumpAx Rad

d) TM

e) MRM

f) HRM

g) TM Rad

h) MRM Rad

i) HRM Rad

Case 4

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

• Systemic Rx a) AC x 4

b) AC x 4 and T x 4

c) Tam x 5 yrs

d) AI x 5 yrs

e) a+c

f) b+c

g) d+c

And what about prevention?

Case 4

• Which order to Rx?a) Surgery, radiation, chemo

b) Radiation, chemo, surgery

c) Chemo, radiation, surgery

d) Chemo, surgery, radiation

e) Doesn’t make a difference

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 optionsa) Lumpectomy

b) Lumpectomy and Rad

c) LumpAx Rad

d) TM

e) MRM

f) HRM

g) TM Rad

h) MRM Rad

i) HRM Rad

Case 5

• Path– Margins close– Nodes 5/23 +– ER+ PR-– Her 2 =– Ki67 63%

• Systemic Rx a) AC x 4

b) AC x 4 and T x 4

c) Tam x 5 yrs

d) AI x 5 yrs

e) a+c

f) b+c

g) d+c

And what about prevention?

Case 5

• Which order to Rx?a) Surgery, radiation, chemo

b) Radiation, chemo, surgery

c) Chemo, radiation, surgery

d) Chemo, surgery, radiation

e) Doesn’t make a difference

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 optionsa) Lumpectomy

b) Lumpectomy and Rad

c) LumpAx Rad

d) TM

e) MRM

f) HRM

g) TM Rad

h) MRM Rad

i) HRM Rad

Case 6

• Path– Margins +– Nodes ?

• Systemic Rx a) AC x 4

b) AC x 4 and T x 4

c) Tam x 5 yrs

d) AI x 5 yrs

e) a+c

f) b+c

g) d+c

And what about prevention?

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 optionsa) Lumpectomy

b) Lumpectomy and Rad

c) LumpAx Rad

d) TM

e) MRM

f) HRM

g) TM Rad

h) MRM Rad

i) HRM Rad

Case 7

• Path– Margins +– Nodes ?

• Systemic Rx a) AC x 4

b) AC x 4 and T x 4

c) Tam x 5 yrs

d) AI x 5 yrs

e) a+c

f) b+c

g) d+c

And what about prevention?