Health-Process-Evidence-based Clinical Practice Guidelines Breast Cancer Locally Advance Breast Cancer Locally Recurrent Breast Cancer Metastatic Breast Cancer

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Health-Process-Evidence-based Clinical Practice
Guidelines Breast CancerLocally Advance Breast
CancerLocally Recurrent Breast CancerMetastatic
Breast Cancer

• Harvey A. Balucating, MD

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• A. Overview of the Problem
• Concept
• B. General Management Guidelines
• Clinical Diagnosis
• Paraclinical Diagnosis
• Prognosis
• Treatment Algorithm

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Clinical Questions

• 1a. What is a operational concept of locally
  advance breast cancers?
• Definition
• - Not considered Early Breast Cancer
• - with no evidence of metastasis
• - This will comprise T4 or Stage III - B

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Clinical Questions

• 1b. What is a operational concept of locally
  recurrent breast cancer?
• Definition
• - reappearance of tumor within the operative
  site after surgical treatment (i.e., mastectomy
  or lumpectomy)

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Clinical Questions

• 1c. What is a operational concept of metastatic
  breast cancer?
• Definition
• - spread of cancer from the primary site (breast
  cancer) and formation of tumor in distant site

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Clinical Questions

• 2a. What are reliable signs and symptoms (more
  than 90 certainty) that will indicate that a
  patient had locally advance breast cancer?
• Ans
• Breast cancer with T4 ( tumor of any size with
  direct extension to the chest wall (not including
  pectoralis muscle) or skin confined to the same
  breast (edema, ulceraqtion, satellite nodule) or
  inflammatory carcinoma with no evidence of
  metastasis

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Clinical Questions

• 2a. What are reliable signs and symptoms (more
  than 90 certainty) that will indicate that a
  patient had locally recurrent breast cancer?
• Ans
• Reappearance of tumor (Breast cancer) after
  surgical treatment (mastectomy or lumpectomy)

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Clinical Questions

• 2a. What are reliable signs and symptoms (more
  than 90 certainty) that will indicate that a
  patient had metastatic breast cancer?
• Ans

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Breast Cancer

• General Management Guidelines
• Clinical Diagnosis
• Paraclinical Diagnosis
• Staging and Prognostication
• Treatment

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1. Clinical Diagnosis

Breast Cancer
EARLY
LOCALLY ADVANCE
METASTATIC
SURGICAL TREATMENT
LOCALLY RECURRENT
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Clinical Questions

• 3a. If a paraclinical diagnostic procedure is
  needed in a patient with locally advance breast
  cancer, what is the most cost-effective procedure
  to do?

Options Benefit Risk Cost Availability
FNAB Pain Bleeding Available
Core Needle Pain Bleeding Available
Open Biopsy Pain Bleeding Available
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Ans.

• FNAB is the standard biopsy procedure for any
  palpable breast mass
• Core needle is done next when FNAB yields
  non-diagnostic results
• Open biopsy if core needle biopsy failed

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Clinical Questions

• 3b. If a paraclinical diagnostic procedure is
  needed in a patient with locally recurrent breast
  cancer, what is the most cost-effective procedure
  to do?
• Ans
• - Physical examination alone adequately detects
  locoregional recurrence due to breast cancer in
  most cases
• - Cytologic or histologic documentation of
  recurrent disease should be obtained whenever
  possible, prior to active treatment
• - Core Needle Biopsy is the initial diagnostic
  procedure in breasr cancer patient with palpable
  locoregional recurrence

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Clinical Questions

• 3c. If a paraclinical diagnostic procedure is
  needed in a patient with metastatic breast
  cancer, what is the most cost-effective procedure
  to do?
• Ans
• -

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Clinical Questions

• 4. What is the 5 year survival rate of the
  following
• Locally advance breast cancer 48
• Metastatic breast cancer Locally recurrent breast
  cancer
• 18

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Treatment
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LOCALLY ADVANCED BREAST CARCINOMA
PRE-OP CHEMOTX
RESPONSE
NO RESPONSE
ADDITIONAL CHEMOTX AND/OR RT
LOCOREGIONAL
NO RESPONSE
NEXT SLIDE
INDIVIDUALIZED TX
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LOCOREGIONAL
LUMPECTOMY SURGICAL AXILLARY STAGING RT
DELAYED BREAST RECONSTRUCTION
TOTAL MASTECTOMY SURGICAL AXILLARY STAGING
RT DELAYED BREAST RECONSTRUCTION
HIGH DOSE RT ALONE
CHEMOTX HORMONAL TX IF Er (),
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LOCALLY RECURRENT
METASTATIC WORK-UP
()
(-)
INITIALLY TREATED WITH MASTECTOMY
INITIALLY TREATED WITH LUMPECTOMY WITH RT
METASTATIC BREAST CA
MASTECTOMY
SURGICAL RESECTION RT (IF POSSIBLE)
CHEMOTX
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METASTATIC BREAST CA
ER/PR POSITIVE OR BONE/SOFT TISSUE ONLY OR
ASYMPTOMATIC VISCERAL
ER/PR NEGATIVE OR SYMPTOMATIC VISCERAL OR
HORMONE REFRACTORY
NO PRIOR ANTIESTROGEN OR 1 YEAR OFF ANTIESTROGEN
PRIOR ANTIESTROGEN WITHIN 1 YEAR
B
SECOND-LINE HORMONAL THERAPY
A
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A
PREMENOPAUSAL
POSTMENOPAUSAL
OVARIAN ABLATION OR SUPPRESSION HORMONAL TX OR
ANTIESTROGEN
AROMATASE INHIBITOR OR ANTIESTROGEN
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B
HER-2b NOT OVER- EXPRESSED
HER-2b OVER- EXPRESSED
CHEMOTX
TRASTUZUMAB CHEMOTX
NO RESPONSE TO 3 SEQUENTIAL REGIMENS OR ECOG
PERFORMANCE STATUS gt 3
CONSIDER NO FIRHTER CYTOTOXIC THERAPY (PALLIATIVE
CARE)