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Harvey A. Balucating, MD

Health-Process-Evidence-based Clinical Practice Guidelines Breast Cancer Locally Advance Breast Cancer Locally Recurrent Breast Cancer Metastatic Breast Cancer. Harvey A. Balucating, MD. A. Overview of the Problem Concept B. General Management Guidelines Clinical Diagnosis

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Harvey A. Balucating, MD

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  1. Health-Process-Evidence-based Clinical Practice Guidelines Breast CancerLocally Advance Breast CancerLocally Recurrent Breast CancerMetastatic Breast Cancer Harvey A. Balucating, MD

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

  3. 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

  4. 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)

  5. 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

  6. 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

  7. 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)

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

  9. Breast Cancer General Management Guidelines Clinical Diagnosis Paraclinical Diagnosis Staging and Prognostication Treatment

  10. Clinical Diagnosis Breast Cancer EARLY LOCALLY ADVANCE METASTATIC SURGICAL TREATMENT LOCALLY RECURRENT

  11. 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?

  12. 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

  13. 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

  14. 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: -

  15. 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%

  16. Treatment

  17. LOCALLY ADVANCED BREAST CARCINOMA PRE-OP CHEMOTX RESPONSE NO RESPONSE ADDITIONAL CHEMOTX AND/OR RT LOCOREGIONAL NO RESPONSE NEXT SLIDE INDIVIDUALIZED TX

  18. LOCOREGIONAL TOTAL MASTECTOMY + SURGICAL AXILLARY STAGING + RT + DELAYED BREAST RECONSTRUCTION LUMPECTOMY + SURGICAL AXILLARY STAGING + RT + DELAYED BREAST RECONSTRUCTION HIGH DOSE RT ALONE CHEMOTX + HORMONAL TX IF Er (+),

  19. LOCALLY RECURRENT METASTATIC WORK-UP (+) (-) METASTATIC BREAST CA INITIALLY TREATED WITH MASTECTOMY INITIALLY TREATED WITH LUMPECTOMY WITH RT SURGICAL RESECTION + RT (IF POSSIBLE) MASTECTOMY CHEMOTX

  20. METASTATIC BREAST CA ER/PR POSITIVE OR BONE/SOFT TISSUE ONLY OR ASYMPTOMATIC VISCERAL ER/PR NEGATIVE OR SYMPTOMATIC VISCERAL OR HORMONE REFRACTORY PRIOR ANTIESTROGEN WITHIN 1 YEAR NO PRIOR ANTIESTROGEN OR 1 YEAR OFF ANTIESTROGEN B SECOND-LINE HORMONAL THERAPY A

  21. A POSTMENOPAUSAL PREMENOPAUSAL OVARIAN ABLATION OR SUPPRESSION + HORMONAL TX OR ANTIESTROGEN AROMATASE INHIBITOR OR ANTIESTROGEN

  22. B HER-2b NOT OVER- EXPRESSED HER-2b OVER- EXPRESSED CHEMOTX TRASTUZUMAB + CHEMOTX NO RESPONSE TO 3 SEQUENTIAL REGIMENS OR ECOG PERFORMANCE STATUS > 3 CONSIDER NO FIRHTER CYTOTOXIC THERAPY (PALLIATIVE CARE)

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