BREAST CANCER 101 A Review of Problems, Diagnostics, and CLINICAL MANAGEMENT - PowerPoint PPT Presentation

View by Category
About This Presentation
Title:

BREAST CANCER 101 A Review of Problems, Diagnostics, and CLINICAL MANAGEMENT

Description:

BREAST CANCER 101 A REVIEW OF ... Clustering of other cancers Genetic Testing Hereditary Breast and Ovarian Cancer Syndrome BRCA1 60-80% lifetime risk breast ... – PowerPoint PPT presentation

Number of Views:559
Avg rating:3.0/5.0
Slides: 54
Provided by: SabhaGan
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: BREAST CANCER 101 A Review of Problems, Diagnostics, and CLINICAL MANAGEMENT


1
BREAST CANCER 101 A Review of Problems,
Diagnostics, and CLINICAL MANAGEMENT
  • Sabha Ganai, MD, PhD
  • Assistant Professor of Surgery
  • Southern Illinois University School of Medicine

2
DISCLOSURES
  • My conflicts of interest are relevant to being a
    practicing surgical oncologist.

3
Objectives
  • Provide an overview of trends in breast cancer
    incidence and mortality
  • Review screening and diagnostic modalities
    important for management of breast cancer
  • Discuss therapeutic approches for breast cancers

4
Breast Cancer
  • 1 in 8 (12.3) lifetime risk for US women
  • Increased from 1 in 11 in the 1970s.

CA Clin J 2014 64 52-62.
5
CA Clin J 2014 64 9-29.
6
CA Clin J 2014 64 9-29.
7
CA Clin J 2014 64 9-29.
8
Breast Cancer Incidence
CA Clin J 2014 64 9-29.
9
Breast Cancer Mortality
10
Breast Cancer Mortality
Breast Cancer Mortality has declined by 34
since 1990.
11
Incidence and Mortality
CA Clin J 2014 64 52-62.
12
Incidence and Mortality
CA Clin J 2014 64 52-62.
13
ACS Screening
CA Clin J 2014 64 52-62.
14
The Controversy
  • What are the harms of mammography?
  • overdiagnosis?
  • more anxiety?
  • more biopsies?
  • time/days off work?
  • more cost?

15
USPSTF (2009)
  • Biennial Mammography ages 50-74
  • The decision to start regular, biennial
    screening mammography before the age of 50 years
    should be an individual one and take into account
    patient context, including the patients values
    regarding specific benefits and harms.

16
Mortality Reduction
  • 71 survival benefit following ACS screening
    guidelines beyond 23 mortality reduction
    achieved following USPSTF guidelines
  • Additional 5 lives saved per 1000 women.

17
Potential Harms
  • Call backs for additional imaging (anxiety)
  • False-positive biopsies
  • False-negative screen
  • Missed breast cancer (dense breasts)
  • Radiation-induced breast cancer risk
  • Over-diagnosis
  • detection of a cancer that might not otherwise
    become clinically-apparent during screen

18
Potential Harms
19
  • Screening women in 40s
  • False-positive mammogram once every 10y
  • False-positive biopsy once every 149y
  • Invitation to treat women in 40s in Swedish
    mammography studies led to 29 reduction in
    breast cancer mortality over 16 years

20
  • Annual vs. Biennual Screening
  • Annual screening leads to 30 lower recall rates,
    detection of smaller tumors, and impact on stage
    migration
  • Screening ages 40 to 79 is more cost-effective
    than seat belts and airbags with regard to
    cost-per-life-year gained
  • Better than drug development

21
  • Adherence and compliance behaviors
  • If womens screening behaviors are established
    earlier, adherence to screening mammography
    improves over time.
  • Women respond to an endorsement of guidelines.
  • Strategy to leave decision-making up in air does
    not educate on risk stratification for breast
    cancer

22
Screening Breast MRI
CA Clin J 2007 57 75-89.
23
Screening Breast MRI
CA Clin J 2007 57 75-89.
24
Screening Breast MRI
Should be limited to centers with biopsy
capabilities
CA Clin J 2007 57 75-89.
25
Genetic Counseling Referral
  • Early-onset breast cancer (lt50y)
  • Triple-negative breast cancer (lt60y)
  • Two breast primaries or breast and ovarian cancer
  • Two or more close blood relatives with breast
    cancer
  • Male breast cancer
  • Pancreas cancer
  • Clustering of other cancers

26
Genetic Testing
  • Hereditary Breast and Ovarian Cancer Syndrome
  • BRCA1
  • 60-80 lifetime risk breast cancer
  • 20-40 lifetime risk ovarian cancer
  • BRCA2
  • 40-60 lifetime risk breast cancer (5-10 male)
  • 10-20 lifetime risk ovarian cancer
  • Pancreas and prostate cancer

27
Genetic Testing
  • PTEN (Cowdens Disease)
  • 25-50 lifetime risk breast cancer
  • Thyroid, endometrial, genitourinary cancers
  • p53 (Li-Fraumeni Syndrome)
  • gt90 lifetime risk breast cancer
  • Sarcomas, brain tumors, adrenocortical tumors,
    colorctal cancers
  • CDH1
  • 40 lifetime risk breast cancer (lobular)
  • Hereditary diffuse gastric cancer

28
Molecular Subtyping
29
Breast Cancer Biology
ER PR HER2
Basal-like (Triple negative) HER2 Luminal (ER)
30
Molecular Subtyping
  • Luminal (Hormone-Receptor)
  • Responsive to tamoxifen and aromatase inhibitors
  • HER2
  • Responsive to trastuzumab and newer biologic
    therapies
  • Basal-like (Triple-negative)

31
Triple Assessment
  • Clinical Exam
  • HP
  • Imaging
  • Diagnostic mammography / ultrasound
  • Pathology
  • Core needle biopsy

32
Biopsy
  • Stereotactic Core Needle Biopsy
  • Ultrasound-guided Core Needle Biopsy
  • If Cancer, should get ER/PR/HER2 IHC
  • Surgical (Excisional) Biopsy
  • Non-concordant results
  • Atypia on a core biopsy
  • Sampling error (10-20)
  • Papillary lesions, radial scars

33
Surgical Management in 1900s
  • William Stewart Halsted
  • Halsted Mastectomy
  • Radical extirpation of breast with pectoralis
    and lymph nodes
  • Predicated on notion that breast cancer spreads
    locally and regionally via lymphatics

34
Paradigm Shift
  • Bernard Fisher
  • 1967 Chairman of National Surgical
    Adjuvant Breast and Bowel Project (NSABP)

35
Paradigm Shift
  • Bernard Fisher
  • because operable breast cancer is a systemic
    disease involving a complex spectrum of
    host-tumor interrelations, local-regional therapy
    is unlikely to affect survival.

36
  • Before 1971, if you had breast cancer, chances
    are youd have to get your breast cut off.
    Surgeons had been taught one thing radical
    surgery saves lives. It was Bernard Fisher who
    changed their minds, getting reluctant breast
    surgeons to enter their cancer patients into
    clinical trials that tested less aggressive
    surgery against the Halsted radical mastectomy. 

37
NSABP B-04
38
NSABP B-06
39
Lowdown
  • Breast-conserving therapy (lumpectomy
    whole-breast radiation) and Mastectomy have
    similar overall survival benefit
  • Includes Triple-negative cancers
  • Goal is clear-at-ink negative margins
  • 2014 SSO/ASTRO guidelines
  • Mastectomy should be paired with referral to a
    Plastics/Reconstructive Surgeon

40
Oncoplastic Techniques
  • Mastectomy
  • Nipple-sparing and Areola-sparing skin-sparing
    approaches
  • Partial Mastectomy
  • Various approaches accounting for location,
    volume and aesthetic considerations

41
What about the Axilla?
42
Axillary Complications
43
(No Transcript)
44
ACOSOG Z0011
  • Only applies to cT1-2N0 patients undergoing
    breast conserving surgery with radiotherapy
  • Observation is acceptable for SLN patients
  • If SLN after mastectomy, Axillary Lymph Node
    Dissection is still recommended

45
(No Transcript)
46
(No Transcript)
47
OncotypeDX
  • 21-gene RT-PCR recurrence score
  • Performed on paraffin-embedded specimens
  • Developed and validated on patient tumor blocks
    from NSABP B-14 (TAM vs. Obs) and B-20 (TAM vs.
    Chemo/TAM)

48
(No Transcript)
49
Hormonal Tx
50
Hormonal Tx
51
Hormonal Tx
Add Chemo
52
The Future
  • Neoadjuvant Clinical Trials
  • Chemo before surgery
  • Assessment of response to therapy
  • Evolving role of surgical management of axilla
  • Bigger surgery does not cure bad biology
  • Optimal screening paradigm in context of better
    imaging strategies and therapies will need to be
    determined
  • An individualized approach?

53
Questions?
About PowerShow.com