1. Breast Cancer 101: KNOWLEDGE IS POWER Jane Lowe Meisel, MD Assistant Professor of Hematology/Oncology Winship Cancer Institute Emory University, Atlanta, GA

2. Young Women With Breast Cancer: A Unique Population Disease and Treatment – Higher stage, aggressive biology – Aggressive treatment Psychosocial distress – Role functioning – Isolation – Lack of information Fertility – 30-60% are concerned about this topic at diagnosis Genetics – Increased risk of a genetic risk factor for cancer

3. …with unique challenges Attention to supportive care and survivorship issues are often not sufficient in young patients: – Body image – Sexual functioning – Fertility – Clarifying genetic risk – Psychosocial issues – Child care/job-related stress

4. Goals for Today Understanding a diagnosis of breast cancer Overview of breast cancer therapy Treatment side effects (short- and long-term) Genetic risk Fertility concerns Life after treatment Metastatic breast cancer

5. Breast Cancer Diagnosis Staging – Early stage – Locally advanced – Metastatic Receptor status – ER/PR (hormone receptors) – HER2

6. Overview of Breast Cancer Therapy Local therapy – Surgery Lumpectomy Mastectomy Prophylactic contralateral mastectomy? – Radiation therapy Systemic therapy – Hormone therapy – Chemotherapy – Targeted therapy

7. Pre-treatment evaluation Could include: – Imaging of the body to look for metastatic disease – Axillary lymph node biopsy – Laboratory testing – Echocardiogram (ultrasound of heart) to evaluate heart function prior to chemotherapy or targeted therapy – Fertility assessment – Genetics

8. Coping with a new diagnosis How can you help? – Be there (helps to have someone to listen, or to distract) – Provide concrete support during the initial workup and as treatment begins…. Providing child care Providing transportation to and from appointments Help with household chores Picking up groceries or prescriptions Cooking meals

9. Pre-treatment evaluation: Genetics Young women with breast cancer are more likely than older women to have a genetic mutation as the cause BRCA1/BRCA2 are the most common mutations associated with breast cancer If a mutation is found, could have implications for families and for treatment – Consideration of bilateral mastectomy – Other risk-reducing procedures

10. Pre-treatment evaluation: Fertility For women who have not yet completed childbearing, important to consider prior to chemotherapy – Reproductive endocrinologist – Consideration of lupron +/- egg harvesting +/- embryo harvesting prior to therapy

11. Timing of therapy for localized disease Neoadjuvant (pre-operative) systemic therapy OR Adjuvant (post-operative) systemic therapy Radiation (after surgery/chemo) – Definitely, if lumpectomy is performed – Possibly, if mastectomy is performed and certain size/lymph node criteria are met

12. Mastectomy – Removes the entire breast and its contents – Can be combined with immediate reconstruction or reconstruction can be done later – Since most of the nerves to the skin are removed, can leave remaining skin numb – Side effects: mild to moderate pain, skin numbness, or bruising seroma (build-up of fluid in the wound)

13. Lumpectomy – Removes only the tumor + surrounding tissue – Radiation therapy is required – Easier recovery than mastectomy, but sometimes re-operation required to get negative margins

14. Lymph node evaluation Sentinel node evaluation vs. lymph node dissection Side effects – Lymphedema – Decreased range of motion – Numbness or pain in underarm area

15. Radiation therapy Goal: to kill any cancer cells left behind after surgery Treatment course: usually 5 days/week for 4-6 weeks Side effects – Skin irritation (like a sunburn) – Chest pain – Fatigue

16. Systemic therapy Chemotherapy – Fatigue – Hair loss – Neuropathy – Nausea/vomiting – Poor appetite – Mouth sores – Decreased blood counts/infection – Decreased fertility

17. Targeted therapy (for HER2+ disease) Trastuzumab +/- Pertuzumab – Fatigue – Rash – Diarrhea – Reversible heart failure – Trastuzumab: visits every three weeks for one year…

18. Endocrine therapy Tamoxifen or ovarian suppression + aromatase inhibitor Side effects – Hot flashes – Mood swings – Vaginal dryness – Decreased libido – Memory loss – Joint pains Duration of therapy: 5-10 years

19. Sexual function Decreased libido and vaginal dryness – Difficult to talk about, but significantly impacts quality of life Can be psychological as well as physiologic (related to chemotherapy/hormone therapy) – Moisturizers – Lubricants – Vagifem – Partner support

20. Resuming a ‘normal’ life Going back to work Resuming family responsibilities Body image (especially postoperatively) Concern about recurrence Sense of vulnerability after treatment ends – No longer ‘actively’ fighting

21. Metastatic breast cancer Breast cancer that has learned to grow outside of the breast/lymph nodes – Common sites of spread: lungs, bone, liver, brain – Less common: lining of abdomen, skin Mostly not curable, but can become like a chronic disease Patients are, for the most part, on some form of treatment for the long term

22. Metastatic breast cancer Treatment can include chemotherapy, targeted therapy, and/or endocrine therapy Treatment can include radiation therapy or even surgery for symptom control Treatment can include clinical trials – So much research in this area

23. Metastatic breast cancer Unique challenges – Continuing ‘life as usual’ when it is profoundly changed – Thinking about personal and professional goals in this context – Isolation can be an issue (loved ones fear ‘saying the wrong thing’ and back away unintentionally)

24. Metastatic breast cancer Everyone wants and needs different things – Offer practical support (transportation, child care, meal preparation, etc) – Help your loved ones get the care they need Cancer-directed care Symptom management – Be truly present Listen, laugh, love

25. Questions??