ryan-breast cancer update

7/31/2019 Ryan-breast Cancer Update

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Update on Breast Care

M. Bernadette Ryan, M.D., FACS

Head, Section of Surgical OncologyMay 18, 2009


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Outline

ANDI concept in benign breast disease

myatalgia

Breast imaging for screening & diagnosis

Breast Cancer

1/2009 update in NCCN guidelines

PBI

Oncotype Dx


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ANDI

Aberrations of normal development andinvolution

concept of benign disorders based onpathogenesis

First published by Hughes et al. in 1987 in

LancetEmbraced slowly in the USA


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ANDI - 2

Bi-directional framework

Horizontal axis: main clinical presentation

normal - aberration - disease

Vertical axis: stages in development

early reproductive (15-25 years)

mature reproductive (25-40 years)

involution (35-55 years)


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ANDI - 3

Normal Process Aberration Disease

Early

Reproductive

15-25 years

Lobular development

Stromal development

Nipple eversion

Fibroadenoma

Adolescent hyperplasia

Nipple inversion

Giant FA or multiple FAs

Gigantomastia

Subareolar abscess/

mammary duct fistula

Mature

Reproductive

25-40 years

Cyclic changes

Epithelia hyperplasia

of pregnancy

Cyclic mastalgia

Nodularity

Ductal papilloma

Bloody nipple discharge

Incapacitating mastalgia

Involution

35-55 years

Lobular involution

microcysts

Duct involution

dilation

sclerosis

Epithelial turnover

Macrocysts, adenosis,

sclerosing lesions

Ductal ectasia

Nipple inversion

Hyperplasia

Periductal mastitis/

abscess

Atypia


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Non - ANDI

Fat necrosis

Lactational abscesses

Contributions of smoking and oro-nipplecontact in non-puerperal abscesses

True neoplasms: phyllodes tumor, tubular

adenoma, lipoma, etc.

Mondors disease, diabetic mastopathy,


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Mastalgia

Probably hormonally related

usually cyclic and ends with menopause

responds to hormone treatment

Many theories:

increased estrogen

decreased progesteroneincreased prolactin

increased end-organ response

low prostaglandin E1 due to EFA deficiency


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Mastalgia - 2

Cyclic or non-cyclic breast pain

rule out chest wall source in non-cyclic

rule out significant lesion with imaginglocalized pain may be due to cancer, cyst,

sclerosing lesion

TreatmentReassurance if mild

Reassurance and primrose oil if moderate

Add drugs if severe (interferes with lifestyle)


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Mastalgia - 3

Cyclic Pain Non-Cyclic

Primrose oil1000-1500 BID

44-58% 27%

Danazol200-400 mg QD

70-80% 30%

Tamoxifen10 mg QD

80-90% 56%

Bromocriptine2.5 mg BID

47% 20%

Placebo 10-40% 10-40%


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Breast Imaging

Mammograms

Ultrasound

MRI

PET scans


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Mammograms

Annual screening beginning at age 40

as young as 25 in high risk groups

upper limit not established

Digital mammogram may be betterespecially in young women and older

women with dense breastsMobile units may increase compliance


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Ultrasound

Initial diagnostic tool in women < 30-35with symptoms or palpable findings

Adjunct to mammographydiagnostic w/u

biopsy

May be used with mammogram to screenwomen at high risk or with dense breasts

no PRS showing survival benefit


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MRI - screening

Screen high risk women

BRCA 1 or 2, TB53 or PTEN mutations

First degree relative with above & untestedLifetime risk 20-25% by model based on FHx

Chest irradiation between ages 10 & 30

Role in women at lesser risk uncertainLCIS, AH, prior breast cancer, 15-20% risk

Not recommended in average risk women


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BRCAPRO

Free programs available

Need extensive family history

age of diagnosis of cancer as well as currentage or age of death of relatives

Calculates risk of harboring BrCa gene

and risk of developing breast & ovariancancer


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BRCAPRO - 2


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BRCAPRO - 3


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BRCAPRO - 4


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MRI - diagnostic

Define extent of disease before BCS

leads to higher mastectomy rate without

clear benefit in local control or survivalDefine extent of disease before & after

neoadjuvant therapy

Look for additional primariesLook for occult primary

Pagets disease & isolated nodal metastases


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PET scan

NCCN recommends against use in stage I-III disease

Biopsy of equivocal or suspicious sites ismore likely to provide useful information

Lobular cancer frequently PET negative

Not useful to stage axillaoverall role in breast cancer unclear


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NCCN updates: DCIS

Minimum margin is still 1 mm

generally decreased failure rates with wider

margins up to 10 mmpost-excision mammogram if uncertainty

Recommends against sentinel node biopsy

reasonable for mastectomyExcision alone in low risk disease

radiation reduces local failure by 50%

equivalent survival


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NCCN: invasive cancer w/u

Genetic counseling if high risk

MRI optional

No PET or PET/CT

ER/PR and Her 2: use a reliable lab

Imaging to rule out metastases only ifsymptomatic

may consider in locally advanced disease


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NCCN - local treatment

Negative margin not defined

Focally + margin acceptable if no EIC

consider higher XRT boost to tumor bed

> 70, T1N0M0, ER/PR +

reasonable to treat with lumpectomy &

tamoxifen or an aromatase inhibitorcan be cN0 or pN0


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NCCN - neoadjuvant

In Stage II & T3N1: only if pt wants BCS

Use in all other Stage III

Consider AI if post-menopausal & ER/PRpositive

cN+: confirm with needle biopsy

Level I & II dissection regardless of response

cN-: SNBx pre- or post-chemo

AxD if +


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NCCN - Radiation

Radiation can be with or without a boost

boost: < 50, close margins, + nodes or LVI

PBI discouraged outside of a trialPost-mastectomy XRT unchanged:

>/= 4 + nodes, >5 cm, margins < 1mm or

+consider in 1-3 nodes

Base XRT on initial clinical stage in

neoadjuvant patients


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Partial Breast Irradiation

Low risk women

age > 45, tumor


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PBI - 2

Treat tumor bed with 1 cm margins

Intra-op: single fraction

Post-op:BID x 10 fractions with total dose 34-38.5 Gy

MammoSite and other balloons

after loading cathetersexternal beam with 3D conformal/IMRT


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NCCN - adjuvant treatment

ER/PR + & Her 2 -: consider Oncotype

Still little data on chemo in women > 70

individualize considering co-morbidities

No prospective randomized data on use ofHerceptin in tumors < 1 cm & node -

but considered reasonable

Baseline & f/u DEXA scans if treat with AIor if menopause induced by treatment


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T1/2, ER/PR+, node -, her 2-

adjuvantonline

age, health, size, grade, nodes, ER/PR

odds of death or recurrence at 10 yearsodds of benefit from adjuvant treatment

Oncotype Dx

21 gene test on paraffin blocksrecurrence score: correlates with 10-year

relapse in tamoxifen-treated patients andwith benefit from chemotherapy


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Tailor X

PRT to determine value of Oncotype

Low RS (1-10): tamoxifen or AI

High RS (> 26): chemotherapy andtamoxifen or AI

Intermediate RS (11-25): randomize

between 2 treatments aboveOff study, 18-30 considered intermediate

about $3000 (some insurances cover test)


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Future

Greater effort to tailor treatment toindividual to avoid toxicity without

jeopardizing survivalPay for performance

accredited breast centers

adherence to national guidelinesvolume of breast cases


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Comments or questions?

ryan-breast cancer update

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