1. So you have Breast Cancer: NOW WHAT??? Barbara A. Ward, MD Medical Director The Breast Center at Greenwich Hospital

2. DO NOT PANIC! Almost everyone survives breast cancer, so why not you? Early detection DOES save lives! Why do you think there are so many breast cancer survivors at those walks?

3. Educate Yourself Buy a book or go to a reliable website: WWW.CANCER.ORG (American Cancer Society) WWW.CANCER.GOV (National Cancer Institute)

4. Find Out The Facts and Get Organized Request a copy of your reports, especially your pathology report. The American Cancer Society provides a Patient Organization Tool, as do many Breast Centers. Are you at the right hospital and doctor?

5. Quality Indicators National Accreditation Program for Breast Centers (NAPBC) Commission on Cancer (CoC) National Cancer Institute Sponsored Site Most University Hospitals Breast or Surgical Oncology Fellowship- Trained Surgeon

6. Multi-disciplinary Care Breast Radiologist Breast Surgeon Reconstructive Surgeon Medical Oncologist Radiation Oncologist

7. Other Team Members Nurse Navigator or Educator Pathologist Tumor Registrar Cancer Counselor Nutritionist Social Worker Physical Therapist

8. Keep it Simple First decision typically involves surgery: What type and Where? Don’t feel bad about getting a second opinion, especially if a mastectomy is recommended

12. Evolution of Surgical Practice Halsted’s Radical Mastectomy Modified Radical Mastectomy 1985: Lumpectomy plus Radiation= same survival rates 2006: Poor cosmetics so reassess surgical strategies

13. Lumpectomy and Radiation Patient Selection: Cancer is localized and can be removed with a margin of normal tissue…………….. (Clear Margins) Surgeon feels that there is good to excellent cosmetic results. Patient willing and able to receive radiation

14. Radiation Therapy Traditional treatment: Whole breast radiation with boost. @ 32 treatments over 6 -7 weeks (minus weekends) Partial breast radiation: possible over 1-2 weeks vs. shortened course of RT to 3 wks May include Mammosite catheter placement…risk of infection and fibrosis.

15. ?????????????????????????? Investigational vs. “Cutting Edge” Recommended in the context of a clinical trial.

16. Nipple-Sparing Mastectomy Progression of Thought: Pre-reconstruction era (@1960’s) there was no attempt, but now there is renewed interest. Biologic considerations include: –SAFETY –COSMESIS – FUNCTION

21. Recommendations: Garcia-Etienne and Borgen (MSK): –Negative lymph nodes –Nipple Sparing Mastectomy for breast cancers less than 2 cm and more than 2.5 cm from nipple –High-risk patients without cancer

22. Recommendations: Ward et al (GH): selective patients with low risk cancers…small and away from the nipple, not including extensive DCIS. Question including BRCA ½ gene carriers (no specific data) High risk patients due to family history, anxiety, and LCIS, ADH

23. Perforator Flap Reconstruction New option for reconstructive surgery BIG operation, but right for the right person Could involve the transfer of tissue from the abdomen or buttocks Seek a specialist in this technique

24. TRAM

25. Perforator Flaps

27. DIEP Flap Technique Skin and fat from the lower abdomen is surgically transformed to form a new breast mound. This is the most often performed procedure since excess fat and skin are usually found in this area - the end result is a "tummy tuck" - as well as a reconstructed breast.

28. DIEP Flap Technique

30. Arterial Anastamosis Double Opposing Clamps and Background are used for arterial anastamoses

32. Immediate DIEP Reconstruction

33. Nipple Sparing Mastectomy

34. Surgical Decisions Identify BRCA1/2 carriers for prophylactic surgery Higher rate of second breast cancer in same or opposite breast Sentinel lymph node surgery: lowers the chance for lymphedema (arm swelling)

35. What is my prognosis? Prognosis is based upon multiple facts from the pathology report: Tumor Size and Grade Lymph Node Involvement Receptor Status Oncotype DX or Mammoprint Score

36. Adjuvant Therapy Prognostic features from surgery, which includes removal of the sentinel node, will determine the need for chemotherapy Estrogen and Progesterone Receptors, Her-2 neu status, and size of tumor Oncotype DX Test, Mammoprint Test also factor into decision tree.

37. Multidisciplinary Team Postoperative meeting with a MEDICAL ONCOLOGIST Presentation at Tumor Board Second Opinion always an option Decisions typically follow NCCN guidelines You are the final decision-maker

38. New Targeted Therapies Herceptin is a new IV treatment targeted at a marker unique to cancer cells It is given over the course of a year…but has resulted in amazing cures Avastin is also targeted at killing the blood vessels that feed cancer growth Results are more preliminary but hopeful

39. “Survivorship” Buzz word for follow-up post treatment NEXT Step Program Nutrition/EXercise/Therapy Counseling and Support Groups

40. What Can You Do? Lead by example regarding screening Quit smoking Buy the Breast Cancer Stamp Contribute to research efforts such as the American Cancer Society Participate in a Clinical Trial as a patient VOLUNTEER AT GILDA’S CLUB!

41. What else can you do? Join the “Army of Women” http://www.armyofwomen.org/

42. (Remember; why are there so many people walking? Because so many are survivors!) Call for cancer information: 1.800.ACS.2345