1. Recent Advances in Breast Cancer
Dr. Aparna Sreevatsa
Consultant Medical Oncologist
Sahyadri Narayana Multispeciality Hospital, Shimoga

2. Case 1 L, 46 yr old lady Breathlessness CXR Pericardial effusion
Pericardial fluid cytology-Adenocarcinoma
B/L mammography spiculated mass in Rt Breast

3. Case 2 P, 36 yr old lady 2nd trimester of Pregnancy
Rt Breast lump 2 wks
USG Rt Breast 2*2cm lesion
FNAC inconclusive
Reassured
USG abdomen in 3rd trimester- liver metastasis

4. Case 3 L, 52 yr old lady Seizures CT Brain –multiple SOL
Examn- Left breast lump with left axillary lymph nodes
Biopsy breast lump- invasive ductal cancer

5. Introduction
Breast cancer is the most common malignancy in USA.

6. Indian Scenario(ICMR 2012-2014)
Breast Cancer most common cancer
(36 cases/1 lakh popln)
Bangalore
Thiruvananthapuram
Chennai
Pune
Incidence of male breast cancer increasing

7. Pathogenesis Genetic disease
Imbalance between oncogenes and tumor suppressor genes
Deficient DNA repair mechanism
Multistep carcinogenesis

8. Risk Factors Age Estrogen Early menarche Late menopause Nulliparity
Age at first child >35yrs
Benign breast lesions with proliferative features
Smoking
Alcohol
Obesity

9. Genetics (BRCA 1 &2)

10. Pathology & Molecular Biology

11. Immunohistochemistry
Estrogen and Progesterone Receptor
HER2/erb B2

12. Molecular Types

14. Molecular types Hormone receptor-positive HER2-negative patients
Hormone receptor-positive HER2-positive patients
Hormone receptor-negative HER2-negative patients
Hormone receptor-negative HER2-positive patients

15. Staging and Management
Stage
Localised
(I & II)
Locally advanced
(III)
Metastatic
(IV)

16. Localised disease( Stage I & II)
Local control
Surgery
Breast Conservation
Prevent Recurrence
Radiotherapy
Chemotherapy
Endocrine therapy/HER2 targetted agents

17. Locally advanced disease (Stage III)
Downstage
Chemotherapy/HER2 targetted therapy
Local control
Surgery
Breast Conservation/MRM
Prevent Recurrence
Radiotherapy
Chemotherapy
Endocrine therapy/HER2 targetted agents

18. Metastatic disease (Stage IV)
Systemic therapy
Chemotherapy
Endocrine therapy
HER2 targeted agents
Bisphosphonates
Local therapy
Palliative- Radiotherapy (bone, brain mets)

19. Chemotherapy q 3 wks Taxane Dosage Remarks Docetaxel 80 to 100 mg/m2
more myelosuppressive
Paclitaxel
80 to 100 mg/m2 on days 1, 8, and 15 of a 28-day cycle
neuropathy and myalgia are greater ; mild-moderate hepatic dysfunction
Nab-paclitaxel
150 mg/m2
Q 3 wks
Hypersensitivity reactions. Hyperglycemia

20. Anthracyclines Anthracycline Dosage Remarks Doxorubicin
doxorubicin 60 mg/m2 q 3 weeks US
Epirubicin
Europe
Pegylated liposomal doxorubicin
50 mg/m2 q 4 weeks or
Lower cardiotoxicity, higher rate of plantar-plantar erythrodysesthesia

21. Platinum agents 
Combination regimen, where DNA damage repair pathways are impaired (BRCA1 mutations and patients with triple-negative breast cancer)

22. Ixabepilone ixabepilone (40 mg/m2 every 21 days) ORR of 19 percent
median duration of response of 5.7 months
Median OS was 8.6 months.
Grade 3 and 4 peripheral sensory neuropathy occurred in 14 percent of patients
Efficacy and safety of ixabepilone (BMS ) in a phase II study of patients with advanced breast cancer resistant to an anthracycline, a taxane, and capecitabine. J Clin Oncol ;25(23):3407.

23. Eribulin 1.4 mg/m2 days 1 and 8 every 21 days less neuropathy(5%)
phase III trial of 762 heavily pretreated patients who were randomly assigned to treatment with eribulin or other chemotherapy (based on physician’s and patient’s choice) (EMBRACE)
significantly improved OS (median, versus 10.6 months
grade 3 and 4 neutropenia in 45 percent of patients, and grade 3 and 4 febrile neutropenia in 5 percent

24. Non-anthracycline, taxane-based regimens
Gemcitabine plus paclitaxel or docetaxel —  Gemcitabine(1250 mg/m2 on days 1 and 8) plus paclitaxel(175 mg/m2 on day 1)
ORR of 41 %
gemcitabine (1000 mg/m2 on days 1 and 8) plus docetaxel(75 mg/m2 on day 1)
ORR of 43 %
Capecitabine plus docetaxel — Capecitabine(1250 mg/m2, twice daily for 14 of every 21 days) plus docetaxel(75 mg/m2 every 21 days) (CD)
ORR of 42 %

25. Endocrine therapy SERM- Tamoxifen
Aromatase inhibitors- Letrozole, Anastrazole, Exemestane
SERD- Fulvestrant
Ovarian suppression
Surgical- Oophorectomy
Medical- GnRH analogues(Leuprolide)
Radiation
Androgen receptor Enzalutamide, Abiraterone

26. HER2 Targeted Therapy Trastuzumab- MAB HER2 (cardiotoxic)
Pertuzumab- MAB HER2
Ado Trastuzumab emtansine-MAB drug conjugate
Lapatinib-TKI HER2

27. Trastuzumab & Pertuzumab

28. Breast Cancer Screening
NCCN/ACS/ACOG
40yrs
Every year
Clinical examination+ B/L Mammography

29. Take Home Message Early breast cancer is a curable disease.
Metastatic disease has survival ranging a few months to 2-3 years.
Breast lump in pregnant & lactating mothers could be breast cancer.
Screening mammography for women aged >40 years.

30. Thank You