1. Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance Professor, Medical Oncology, University of Washington School of Medicine Member, Clinical Division, Fred Hutchinson Cancer Research Center Treatment Overview: The Multidisciplinary Team

2. Breast Cancer Treatment: A Multidisciplinary Team Approach RadiologyRadiology PathologyPathology SurgerySurgery Radiation OncologyRadiation Oncology Medical OncologyMedical Oncology Fighting the Crab – Kiev, Ukraine

3. Personalized Cancer Medicine New Strategies in Treating Breast Cancer: Better Targeting Better Targeting Individualized Approaches

4. Cancer Treatment: Defining the Cancer The first step in designing the treatment plan is carefully defining the cancerThe first step in designing the treatment plan is carefully defining the cancer –Clinical examination –Radiology tests –Pathology tests –Blood tests

5. Diagnosing the Cancer: Ultrasound- Guided Breast Biopsy

6. Defining the Cancer: Pathology Treatment recommendations are aided with the help of pathologic factorsTreatment recommendations are aided with the help of pathologic factors –Prognostic factors: aid in estimating likelihood of cancer recurrence and death –Predictive factors: predict likelihood of response to a given therapy

7. The First Step in Making a Treatment Plan for Breast Cancer: Defining the Cancer StageStage –Tumor size –Lymph node status –Metastatic sites GradeGrade Surgical marginsSurgical margins Tumor expression of genes and proteinsTumor expression of genes and proteins –Estrogen receptor (ER) –Progesterone receptor (PR) –HER-2 Estrogen Receptor Invasive Breast Cancer HER-2

8. Defining the Cancer: Radiology Radiologic imaging can help determine the location and spread of the cancerRadiologic imaging can help determine the location and spread of the cancer –Local extent –Regional lymph nodes –Distant spread (metastases)

9. Mammogram: Area of abnormality extends over 60 mm Evaluating Extent of Local Disease: Breast Cancer

10. Bone Scan Staging for Distant Disease: Breast Cancer Multiple bone metastases Patient A The most common sites of distant disease in breast cancer are the bones, liver and lungs

11. Breast Cancer Surgery Sometimes “less” surgery is better Mastectomy vs. lumpectomyMastectomy vs. lumpectomy Lymph node dissection vs. sentinel lymph node biopsyLymph node dissection vs. sentinel lymph node biopsy

12. Lumpectomy: Wire Localization of Non- Palpable, Imaging-Detected Breast Cancers

13. Lumpectomy Margin Evaluation: Inking the Tumor Specimen in the Operating Room

14. Sentinel Lymph Node Biopsy 1. Inject around area of tumor with blue dye, radioactivity, or both 2. Track the lymphatic drainage of the tumor sentinel node biopsy requires substantial technology, resources, and training

15. Breast Cancer Radiation Therapy The future: is “less” radiation sometimes better?The future: is “less” radiation sometimes better? –Whole breast versus partial breast radiation (brachytherapy) –Hypofractionation (shorter course) –3D conformal radiation planning

16. Indications for Radiation Therapy After Mastectomy Tumor size > 5 cmTumor size > 5 cm Inflammatory features or skin involvementInflammatory features or skin involvement Multiple positive lymph nodesMultiple positive lymph nodes Extracapsular lymph node extensionExtracapsular lymph node extension Positive surgical marginsPositive surgical margins

17. Systemic Therapy for Breast Cancer Endocrine Therapy Chemotherapy Biologically-targeted Therapy New Strategies: Individualizing treatment to the cancer and the patient

18. Identifying New Targets in the Treatment of Breast Cancer Death Receptors Tubulin- interacting Agents HDAC Inhibitors Metastasis Inhibitors Anti- Angiogenesis HER-2 Inhibitors IGF-R Inhibitors MUC-1 Antibodies Proteosome Inhibitors mTOR Inhibitors Farnesyl Transferase Inhibitors Mdm2 Inhibitors Pro-apoptotic Drugs Kinesins Aurora Kinase Inhibitors MEK Inhibitors HIF Inhibitors Raf Inhibitors EGFR Inhibitors HSP90 Inhibitors Src Inhibitors Cell Cycle Inhibitors

19. Optimizing Health and Wellness After Treatment of Breast Cancer: Survivorship Many breast cancer patients can look forward to a long life after treatmentMany breast cancer patients can look forward to a long life after treatment Breast cancer patients and their health care team need to pay attention to all aspects of health and well-beingBreast cancer patients and their health care team need to pay attention to all aspects of health and well-being Team Survivor Northwest