Lecture 19 Treating Breast Cancer New Recommendations for Mammograms as of Tuesday For women at average risk Change from starting annual mammogram screening at 40 to 45 At 55 biennial screenings if choose to Goal to reduce false positives and unnecessary treatments Controversy since 2009 Breast Cancer Stage and Survival Stage 1 97 5 years and 95 10 years Stage 2 early 87 5 years and 81 10 years Stage 2 late 77 5 years and 65 10 years Stage 3 59 5 years and 44 10 years Stage 4 26 5 years and 16 10 years Staging Breast Cancer TNM T tumor size N Axillary lymph nodes M Metastasis Sentinel Lymph Node Biopsy Sentinel Lymph node First node s draining a cancer Hypothesized first nodes to be invaded from primary tumor site Inject dye into tumor to identify sentinel nodes Lymph Node Status Chances of Surviving 5 years Chances of surviving 10 years No cancer in any node Cancer in one to three nodes Cancer in four or more nodes Better than 90 Better than 80 About 60 to 70 About 40 to 50 About 25 to 40 About 40 to 50 About 25 to 40 About 15 to 35 Chances of surviving 10 years without recurrence Better than 70 Sentinel Lymph Node Detection Before going to the operating room the surgeon injects a small dose o low level radioactive tracer called technetium 99 into the breast in the region of the patient s tumor Technetium 99 contains less radiation than a standard x ay CT scan or bone scan and is a relatively safe substance Half life is less than 6 hours A blue dye is also injected to help visually track the location of the sentinel node during surgery The surgeon then uses a hand held counter to detect the radioactive tracer and locate the sentinel node An Alternative for DCIS Treatment Is the cure worse than the disease 10 2 2015 Basila sat back down and as their meeting reached the hour mark she made a choice that humans are practically hardwired not to make in the face of a cancer diagnosis she decided to do nothing Not nothing exactly she would start taking a drug called tamoxifeln that blocks estrogen which can fuel tumor growth And she would enroll in a clinical trial involving active surveillance twice a year visits in which she would get mammograms alternating with MRIs As long as there were no worrisome changes Basila would be spared arsenal in breast cancer treatment surgery radiation and chemotherapy Rethinking the Standard for Ductal Carcinoma In Situ Treatment Is there a benefit to surgery and radiation For some women with Stage 1 and 2 breast cancer 1 survival benefit from double mastectomies 100 000 women study found no matter what the treatment for DCIS mortality risk stays the same as the general population Removal of 60 000 DCIS lesions annually has not been accompanied by a reduction in the incidence of invasive breast cancers When does DCIS signify a greater risk Diagnosed at a young age before 40 some lesions do pose an increased risk of breast cancer specific mortality African American women higher risk for HR breast cancer and women with HR or HER2 DCIS should continue standard aggressive treatment In total these DCIS high risk groups probably constitute approximately 20 of DCIS cases Effects of Radiation Therapy in most cases of DCIS Radiation therapy after lumpectomy does not lead to a reduction in breast cancer mortality In fact may be slight increase in mortality with radiation therapy As of August 2015 recommendation is to leave radiation for invasive cancers What about Desiree Basila and her choice to wait and see For the lowest risk lesions observation and prevention interventions alone should be tested Diet exercise moderate alcohol intake and avoidance of postmenopausal hormone therapy with progesterone containing regimens Breast Cancer Treatment Options Treatment options dependent on the stage of cancer Local or regional tumor Treated with surgery radiation or chemotherapy Systemic treatments are directed to the whole body or system for metastasized cancers Complementary and Holistic Therapies Complementary treatment options Simple and Radical Mastectomy Simple covers less area Radical covers a large area Surgery for Breast Cancer Lumpectomy Breast conserving surgery Wide excision Breast conserving surgery Quadrectomy Beast conserving surgery Mastectomy Breast removal Radical Mastectomy not Always Life Saving Very Rarely Necessary Conclusion The long term survival rate among women who undergo breast conserving surgery is the same as that among women who undergo radical mastectomy Breast conserving surgery is therefore the treatment of choice for women with relatively small breast cancers Radiation Therapy vs Brachytherapy Radioactive material placed in body in the area near cancer cells internal radiation therapy implant radiation or brachytherapy Benefit Radiation dose targets lumpectomy cavity minimizes normal tissue exposure Chemotherapy A Port B Catheter tubing C Subclavian vein D Superior Vena Cava E Pulmonary Vein F Aorta G Heart HER 2 Breast Cancer and Herceptin Cell from body s own defense system Without Herceptin the HER2 cancer cell keeps telling itself to grow and divide into more cancer cells 1 Herceptin attaches to a HER2 cancer cell and tells your body s defense system to target the HER2 cancer cell 2 Herceptin may also stop the HER2 cancer cell from telling itself to grow and divide into more cancer cells Hormone Therapy What percentage of Breast Cancer have Hormone Receptors 75 of breast cancers are estrogen receptor ER positive or ER 65 of ER positive breast cancers are also progesterone receptor positive PR positive or PR Approximately 25 of breast cancer patients have tumors that are HER2 Why is Hormone Receptor Status Important in Breast Cancer Treatment 75 of breast cancers are estrogen receptor positive ER positive or ER 65 of ER breast cancers are also progesterone receptor positive PR positive or PR Approximately 25 of breast cancer patients have tumors that are HER2 We can block HER2 receptors with Herceptin We can block estrogen receptors with SERMs SERMs bind to any ER in the body They do not allow activation of transcription factors in breast tissue thus no breast tumor growth Anti Estrogens Selective Estrogen Receptor Modulators SERMs Binds to receptor and makes unavailable to estrogen broken key in lock Partially effective at activating cell growth in uterine cells tamoxifen SERM estrogen in breast cell Breast receptor not activated No breast cell SERM Estrogen receptor in uterine cell Uterine receptor activated carcinogens in
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