Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance

1. 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

2. Breast Cancer Treatment: A Multidisciplinary Team Approach • Radiology • Pathology • Surgery • Radiation Oncology • Medical Oncology Fighting the Crab – Kiev, Ukraine

3. Personalized Cancer Medicine New Strategies in Treating Breast Cancer: Better Targeting Individualized Approaches

4. 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

5. Diagnosing the Cancer: Ultrasound-Guided Breast Biopsy

6. 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

7. 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

8. Defining the Cancer: Radiology • Radiologic imaging can help determine the location and spread of the cancer • Local extent • Regional lymph nodes • Distant spread (metastases)

9. Evaluating Extent of Local Disease: Breast Cancer Mammogram: Area of abnormality extends over 60 mm

10. 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

11. Sometimes “less” surgery is better • Mastectomy vs. lumpectomy • Lymph node dissection vs. sentinel lymph node biopsy Breast Cancer Surgery

12. Lumpectomy: Wire Localization of Non-Palpable, Imaging-Detected Breast Cancers

13. Lumpectomy Margin Evaluation: Inking the Tumor Specimen in the Operating Room

14. 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

15. 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

16. 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

17. Systemic Therapy for Breast Cancer Endocrine Therapy Chemotherapy Biologically-targeted Therapy New Strategies: Individualizing treatment to the cancer and the patient

18. 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

19. 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