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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. BREAST CANCER 101 A Review of Problems, Diagnostics, and CLINICAL MANAGEMENT. My conflicts of interest are relevant to being a practicing surgical oncologist. DISCLOSURES. Objectives.

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

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

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

  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 patient’s 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 women’s 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 (<50y) • Triple-negative breast cancer (<60y) • 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 (Cowden’s Disease) • 25-50% lifetime risk breast cancer • Thyroid, endometrial, genitourinary cancers • p53 (Li-Fraumeni Syndrome) • >90% 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 • H&P • 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 andlymph nodes • Predicated on notion that breast cancer spreads locallyand regionally via lymphatics

  34. Paradigm Shift • Bernard Fisher • 1967 – Chairman of National Surgical AdjuvantBreast and Bowel Project(NSABP)

  35. Paradigm Shift • Bernard Fisher • “because operable breastcancer is a systemic disease involving a complexspectrum of host-tumorinterrelations, local-regionaltherapy is unlikely to affectsurvival.”

  36. “Before 1971, if you had breast cancer, chances are you’d 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. 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

  44. OncotypeDX • 21-gene RT-PCRrecurrence score • Performed on paraffin-embeddedspecimens • Developed and validated on patient tumor blocks from NSABP B-14 (TAM vs. Obs) and B-20 (TAM vs. Chemo/TAM)

  45. Hormonal Tx

  46. Hormonal Tx

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