Breast Cancer Treatment Three parts –Local/regional therapy –Systemic therapy –Prevention Weigh risk/benefit ratio Timing Overall impact on survival

Local/regional therapy Surgery –Halsted Radical Mastectomy –Modified Radical Mastectomy ( Patey) –Total Mastectomy –Lumpectomy –LumpAx Radiation – reduces LR ½- ¾ and decreases deaths for ¼ recurrences prevented post mastectomy –Whole breast –5 field –Partial breast ( mammosite)

Systemic therapy Prognostic signs –Size, nodes (sentinel vs regular), grade Predictive signs –ER, PR, Ki 67, Her-2, etc. Two major types –Cytotoxic – reduces death rate about 1/3 Antracyline based Taxane based Herceptin enhancement –Hormonal Tamoxifen (SERM) – reduces death rate about 1/4 Aromatase Inhibitors – reduces death rate about 1/3 Ovarian ablation, etc.

Prevention TAM – reduces incidence of new cancers 49% if first ca was ER+ AI’s – reduce incidence of new cancers post-menopausally by 75-78% if first ca was ER+ PMastectomy reduces risk by > 95%

Case 1 47 y.o. WF 1.2 cm IDC detected on annual mammo –MA 11 –PG 31 –Fam hx – 51 –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

Case 1 Path –Margins negative –Nodes negative –ER+ PR+ –Her 2 – –Ki67 18% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

Case 1 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

Case 2 27 y.o. WF 2.2 cm ILC detected on SBE –MA 9 –PG none –Fam hx – M and 2 Sisters –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

Case 2 Path –Margins negative –Nodes 1/6+ –ER- PR- –Her 2 + –Ki67 48% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+ herceptin f)b+ herceptin g)d+c + herceptin And what about prevention?

Case 2 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

Case 3 53 y.o. WF 0.6 cm IDC with DCIS detected on annual mammo –MA 11 –PG 31 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

Case 3 Path –Margins negative –Nodes negative –ER+ PR+ –Her 2 – –Ki67 18% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

Case 3 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

Case 4 83 y.o. WF with DCIS detected on annual mammo –MA 11 –PG 22 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

Case 4 Path –Margins negative –Nodes ? –ER+ PR+ –Her 2 – –Ki67 18% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

Case 4 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

Case 5 53 y.o. WF 6cm IDC with DCIS detected on PE –MA 11 –PG 31 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node positive on exam –Erythema and edema on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

Case 5 Path –Margins close –Nodes 5/23 + –ER+ PR- –Her 2 = –Ki67 63% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

Case 5 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

Case 6 53 y.o. WF with LCIS detected on excision of FA –MA 11 –PG 31 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

Case 6 Path –Margins + –Nodes ? Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

Case 7 55 y.o. BF with ADH found on core bx –MA 9 –PG 21 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

Case 7 Path –Margins + –Nodes ? Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?