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Treatment Overview: The Multidisciplinary Team. Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance Professor, Medical Oncology, University of Washington School of Medicine Member, Clinical Division, Fred Hutchinson Cancer Research Center.
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Treatment Overview: The Multidisciplinary Team Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance Professor, Medical Oncology, University of Washington School of Medicine Member, Clinical Division, Fred Hutchinson Cancer Research Center
Breast Cancer Treatment: A Multidisciplinary Team Approach • Radiology • Pathology • Surgery • Radiation Oncology • Medical Oncology Fighting the Crab – Kiev, Ukraine
Personalized Cancer Medicine New Strategies in Treating Breast Cancer: Better Targeting Individualized Approaches
Cancer Treatment: Defining the Cancer • The first step in designing the treatment plan is carefully defining the cancer • Clinical examination • Radiology tests • Pathology tests • Blood tests
Defining the Cancer: Pathology • Treatment recommendations are aided with the help of pathologic factors • Prognostic factors: aid in estimating likelihood of cancer recurrence and death • Predictive factors: predict likelihood of response to a given therapy
The First Step in Making a Treatment Plan for Breast Cancer:Defining the Cancer • Stage • Tumor size • Lymph node status • Metastatic sites • Grade • Surgical margins • Tumor expression of genes and proteins • Estrogen receptor (ER) • Progesterone receptor (PR) • HER-2 Invasive Breast Cancer Estrogen Receptor HER-2
Defining the Cancer: Radiology • Radiologic imaging can help determine the location and spread of the cancer • Local extent • Regional lymph nodes • Distant spread (metastases)
Evaluating Extent of Local Disease: Breast Cancer Mammogram: Area of abnormality extends over 60 mm
Staging for Distant Disease: Breast Cancer Patient A Bone Scan Multiple bone metastases The most common sites of distant disease in breast cancer are the bones, liver and lungs
Sometimes “less” surgery is better • Mastectomy vs. lumpectomy • Lymph node dissection vs. sentinel lymph node biopsy Breast Cancer Surgery
Lumpectomy: Wire Localization of Non-Palpable, Imaging-Detected Breast Cancers
Lumpectomy Margin Evaluation: Inking the Tumor Specimen in the Operating Room
Sentinel Lymph Node Biopsy sentinel node biopsy requires substantial technology, resources, and training 1. Inject around area of tumor with blue dye, radioactivity, or both 2. Track the lymphatic drainage of the tumor
Breast Cancer Radiation Therapy • The future: is “less” radiation sometimes better? • Whole breast versus partial breast radiation (brachytherapy) • Hypofractionation (shorter course) • 3D conformal radiation planning
Indications for Radiation Therapy After Mastectomy • Tumor size > 5 cm • Inflammatory features or skin involvement • Multiple positive lymph nodes • Extracapsular lymph node extension • Positive surgical margins
Systemic Therapy for Breast Cancer Endocrine Therapy Chemotherapy Biologically-targeted Therapy New Strategies: Individualizing treatment to the cancer and the patient
Identifying New Targets in the Treatment of Breast Cancer HER-2 Inhibitors Metastasis Inhibitors IGF-R Inhibitors EGFR Inhibitors MUC-1 Antibodies Anti-Angiogenesis Src Inhibitors mTOR Inhibitors Farnesyl Transferase Inhibitors MEK Inhibitors HIF Inhibitors Cell Cycle Inhibitors Aurora Kinase Inhibitors HSP90 Inhibitors Raf Inhibitors Pro-apoptotic Drugs Proteosome Inhibitors Mdm2 Inhibitors Kinesins HDAC Inhibitors Tubulin-interacting Agents Death Receptors
Optimizing Health and Wellness After Treatment of Breast Cancer: Survivorship • Many breast cancer patients can look forward to a long life after treatment • Breast cancer patients and their health care team need to pay attention to all aspects of health and well-being Team Survivor Northwest