breast cancer video 2
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These are the slides that accoTRANSCRIPT
BREAST CANCER
Robert Miller MDwww.aboutcancer.com
Decisions that need to be made about treating breast cancer
NCCN.org
Treatment Decisions
1. Surgery: mastectomy versus conservation (lumpectomy)
2. Adjuvant Therapy: hormone therapy, chemotherapy, targeted therapy
3. Radiation: whole breast or partial breast (balloon)
Treatment Decisions
The woman should be assisted by a multi-disciplinary team, including a surgeon, possibly a plastic surgeon, medical oncologist and a radiation oncologist
Woman with lumpectomy.A dark area indicates tumorB light pink highlighted area indicates tissue removed at lumpectomy
Woman with modified radical mastectomy.A pink highlighted area indicates tissue removed at mastectomyB axillary lymph nodes: levels IC axillary lymph nodes: levels IID axillary lymph nodes: levels III
Deciding on Surgery
Operable Breast Cancer: In Defense of Conservative SurgeryCA: A Cancer Journal for Clinicians
Volume 23:November/December 1973. George Crile Jr.
Survival Comparisons Between the Cleveland Clinic (no mastectomies) with National Cancer Registry (mastectomies)
Cleveland Clinic virtually abandoned radical mastectomies in 1957
Prospective Randomized Trials Comparing Conservation Surgery with Mastectomy in Early Stage Breast Cancer
Survival Comparisons Between Conservation Surgery (CS) plus Radiation (RT) versus Mastectomy
10 year survival of 112,154 women with stage I/II breast cancer comparing lumpectomy / radiation with mastectomy.
Radiation has a better long term survival than mastectomy
Mastectomy or Lumpectomy
Results of Randomized Trials Comparing Conservation Surgery (CS) With or Without PostOp Radiation (RT)
Reasons to Favor Mastectomy over Conservation/Radiation
Breast Conservation
Lumpectomy (remove the cancer with a small rim of normal tissue, clear margins)
Sentinel node biopsy will often be performed at the same time
Level 1 and 2 Nodes May be Removed, depending on the status of the sentinel node
biopsies
At the time of the lumpectomy the surgeon tries to remove the cancer with a margin of normal breast tissue around the mass
X-ray image of the lumpectomy specimen
Deciding on the necessity and benefits of hormone therapy or chemotherapy
Before radiation, a decision needs to be made about the need for systemic therapy (hormone therapy or chemotherapy)
NCCN.org
Genetic ProfilesMay show that some women with favorable breast cancer (estrogen + and node -) may need more than just Tamoxifen / analyze the cancer for the presence (expression of 21 breast cancer genes)
Genetic ProfilesMay show that some women with favorable breast cancer (estrogen + and node -) may need more than just Tamoxifen
27% of women had a high risk gene profile and 30.5% relapsed after Tamoxifen and they may have done better with chemotherapy
Online Breast Cancer Calculators www.aboutcancer.com
www.adjuvantonline.com
For this elderly woman with a low risk cancer, the benefits from hormone therapy (0.3%) or chemotherapy (0.1%)would be very small and she would probably decide not to take either
Benefits of intensive chemotherapy in a young woman with high risk cancer
For this young woman with high risk cancer, the benefits from chemotherapy would be very large (10 year survival would move from 33.5% to 51%) and she almost always would agree to it
Deciding on Radiation
Then a decision about the need for radiation and how large should the radiation target be
CT scan is obtained at the time of simulation
CT images are then imported into the treatment planning computer. Note that at the time of the simulation the patient may receive 3 small tattoo marks
Computer generated anatomy images that will identify all the important structures to be sure the radiation covers the area of breast cancer and limits the dose to other areas
Viewed from the side, the radiation stops before hitting the lung
Typical technique for external beam
Radiation beam skims over the surface of the chest wall, ribs and luring
If the radiation does not go deep enough the cancer can grow back (the areas in the red)
note: cases are from a textbook and not treated here at Wellspring
Radiation Technique
External Beam Radiation
Monday through Friday for 5 weeks
After a lumpectomy the whole breast is radiated for about 5 weeks (the red box) and then a boost dose (5 – 7 treatments) is given to the lumpectomy site (blue circle)
Radiation
Fields
Sometimes along with radiation to the breast, the high nodes in the neck (supraclavicular nodes) may be treated (the NCCN guidelines recommend these nodes be treated if there was cancer in the axilla)
The whole breast treated 26 to 28 times
The lumpectomy site is then treated 5 to 7 times
Whole breast treated with X-rays from side to side, and skims the surface of the lung or pleura
Phase 1 External Beam Radiation (X-rays)
lumpectomy
Lymph node
Phase 2 External Beam Radiation (electron beam)
Electron beam is used to target straight on the area of the lumpectomy (and the radiation does not penetrate deeply)
lumpectomy
Generally the side effects of breast radiation do not become noticeable until the woman has received about 10 to 15 treatments, and then become somewhat more noticeable through the rest of the treatment. The most common side effects:
•skin irritation - the skin that is radiated gets red, itchy and may blister (like a sun burn) may lose hair in arm pit (biafine, prutect, myaderm, aquaphor, silvadene, triamcinalone, Radiaderm)
•breast or chest wall tenderness or mild pain
•tiredness or fatigue (some women feel a little light-headed)
•are swelling or edema
Short Term Side Effects of Breast Radiation
By 2 to 3 weeks the skin burn has healed up almost completely
Long Term Side Effects of Breast Radiation
• Arm swelling or lymphedema is probably less than 3%
• Lung inflammation (pneumonitis) is 5% or less• Risk of rib fracture is less than 3%• Risk of nerve damage (brachial plexopathy) < 1%• Radiation fibrosis to breast• Risk of causing a new cancer is less than 1%
BREAST CANCER
Robert Miller MDwww.aboutcancer.com