Multi Disciplinary Cancer Multi Disciplinary Cancer Management –Breast Management –Breast CancerCancerDr Masalu N. MDMedical Oncologist
Breast Cancer Statistics IIMedical Oncologist
•Nearly 50% of diagnoses and 60% of breast cancer deaths occur in underdeveloped countries•Breast cancer 5 year survival ~89% in US (survival 75.2% in 1975), less than 40% in low income countries •Screening reduces deaths from breast cancer in developed countries; impact of screening unknown in low income countries
CA Cancer J Clin 2011, NCI SEER 2012, Lancet Oncology 2008
StageStage 5 year survival5 year survival0 100%I 100%II 93%III 72%IV 22%
Most breast cancer cases in Tanzania present with stage IIIB or IV disease
*NCI seercancer.gov
Breast Cancer Survival According to Stage at
DiagnosisMedical Oncologist
Over 90% of US breast cancer cases present with localized or regional disease (nodes)*
Ductal Carcinoma In-Situ (DCIS) of the Breast
Pathologist• Clinical presentation: Incidental finding,
mass, abnormal mammogram• Natural history: Limited studies but up to
30% of women with partially resected lesions develop invasive cancer at 6-10 years
• Treatment: Mastectomy (99% cure) vs. lumpectomy +/- XRT
• Consider endocrine therapy for five years, especially if tumor ER positive
Lobular Carcinoma In-SituPathologist
• Clinical presentation: May lack mammographic signs, incidental, more common in premenopausal women, often multifocal or bilateral
• Natural history: Not a cancer but marker for increased risk (subsequent carcinoma in opposite breast 50% of the time and more often ductal histology)
• Risk of invasive cancer: ~1% annually• Treatment: Cautious observation, rarely
prophylactic bilateral mastectomy
Community
VolunteersSpiritual counselor Nurse
Hospice workerPhysical therapist
Pharmacist
Physician Psychologist
SocialWorker
Family
Patient
Interdisciplinary TeamInterdisciplinary TeamMedical OncologistMedical Oncologist
Normal cells know :
• When to grow• How to differentiate • When to stop growing • When to die (apoptosis)
Neoplastic cells:
• Grow too much• Do not differentiate• Do not stop growing• Do not die
Malignant cancer cells can metastasize (spread
Pathologic features important in Pathologic features important in determining breast cancer determining breast cancer
treatmenttreatmentEstrogen and Progesterone receptors are located in
the nucleus of the cell and are important factors in cell growth
Estrogen and progesterone receptor status, HER-2/neu, +/- Ki-67 status have documented clinical usefulness as tumor markers and choice of therapy
Molecular profile (costly; limited access)
Breast Cancer SubtypesBreast Cancer SubtypesPathologistPathologist
Subtype Pathology Prevalence
Characteristics
Luminal A ER and/or PR +HER2-Low Ki67Grade 1-2
30-70% -Best prognosis-Fairly high survival rates-Fairly low recurrence rates
Luminal B -ER and/or PR +-HER2+ or HER2- and high Ki67-Higher tumor grade -Larger tumor size-More often node+
10-20% -Prognosis good, but-Survival not as high as luminal
Triple negative (basal-like)
ER and PR-HER2-
15-20% -Aggressive -Poorer prognosis in first 5 years
HER2 Type ER and PR-Typically HER2+
5-15% -Younger age-Outcome improved with introduction of anti-HER2 agents
Treatment of cancer is multidisciplinaryTreatment of cancer is multidisciplinary Medical Oncologist Medical OncologistSurgery Tumor removalRadiation DNA DamageChemotherapy DNA Disruption or damageTargeted Therapy Selective signal blockingGene Therapy Replacement of gene function
FUTURE: Personalized therapy“Identify which therapy will be more successful for each
patient”
Primary Consultation: MS• MS is 52 years old• She works as a manager• She has had a mass in her left breast for one
year
• No pain• No nipple secretion• No skin changes or
swollen glands
Pregnancies 4Deliveries 3Menarche at age 12; last period at 50Never had a breast biopsy
• Mother breast cancer at age 62 and a second primary at age 68
• Sister breast cancer at age 57• Maternal aunt breast cancer at age 59
• Maternal aunt ovarian cancer at age 68• Maternal uncle colon cancer at age 65• HBOC,BRCA1,BRCA2,LYNCH SYNDROME-
HNPCC
Family HistoryFamily History
• Vital signs: Temp 36.2 Pulse 89 Blood Pressure 137/67
• A large 6x8 cm movable breast mass, without skin changes
• Axilla: Several enlarged lymph nodes
• Supraclavicular and cervical nodes: negative
• Liver feels normal
Should we order a Should we order a mammogram?- Radiologistmammogram?- RadiologistA. No needB. Only for the affected breastC. Only for the normal breastD. Mammogram for both breasts prior to
biopsyE. Not now, only after treatment
Craneo-CaudalMedio-LateralCraniocaudalMediolateral
Patient mammogram BIRAD 5Patient mammogram BIRAD 5
What should the primary What should the primary physician do? -Radiologistphysician do? -RadiologistA. Refer to surgeon for biopsyB. Refer for chest x-ray and bone scanC. Give antibioticsD. Removal of breast without biopsyE. Send home with pain medicines
Surgeon’s checklistSurgeon’s checklist
Need to order mammogram if not already done Need to confirm diagnosis with tissue biopsyRemember to order receptors estrogen,
progesterone, Her2-neu and Ki-67Consider staging tests for locally advanced
disease
What kind of biopsy would you What kind of biopsy would you do? Surgeondo? SurgeonA. Core-needle biopsyB. Fine-needle aspirationC. Excisional biopsyD. Punch biopsyE. None of the above
Tissue –Sent to Pathologist
Information given:
-Breast “lump”-Do receptors (estrogen, progesterone, Her2-neu, Ki-67)
Is this enough information for the pathologist?
Normal breast (skin, fat, breast tissue)
Hyperplasia with calcifications: Hematoxylin & Eosin
Ductal infiltrating carcinoma
Estrogen Receptor
Progesterone Receptor
Pathology Report:
-Infiltrating Ductal Carcinoma Grade III some areas of in situ cancer
-Estrogen and progesterone receptors negative, HER2-neu not amplified, Ki-67 25%
Breast Cancer SubtypesBreast Cancer SubtypesSubtype Pathology Prevalen
ceCharacteristics
Luminal A ER and/or PR +HER2-Low Ki67Grade 1-2
30-70% -Best prognosis-Fairly high survival rates-Fairly low recurrence rates
Luminal B -ER and/or PR +-HER2+ or HER2- and high Ki67-Higher tumor grade -Larger tumor size-More often node+
10-20% -Prognosis good, but-Survival not as high as luminal
Triple negative (basal-like)
ER and PR-HER2-
15-20% -Aggressive -Poorer prognosis in first 5 years
HER2 Type ER and PR-Typically HER2+
5-15% -Younger age-Outcome improved with introduction of anti-HER2 agents
What investigations would you What investigations would you do to complete the staging?-do to complete the staging?-RadiologistRadiologist
Laboratories?CXRChest CT?Abdominal ultrasound?Abdominal CT scan?CT scan brain?Bone scan?PET scan?
Please discuss
Patient Summary-RadiologyPatient Summary-RadiologyMammogram right breast normal
6x8cm mass left breast – highly suspicious for malignancy BIRAD 5
Pathology reports infiltrating ductal carcinoma, high grade(III)
ER and PR negative, Her2-neu not amplified (triple negative)
Staging studies negative
MS Case Summary-Medical OncologyMS Case Summary-Medical OncologyMammogram right breast normal6x8cm mass left breast – highly suspicious for
malignancy BIRAD 5Pathology reports infiltrating ductal carcinoma, high
gradeER, PR negative, Her2-neu not amplified (Triple
negative)Staging studies negativeClinical Stage: T3 N2 M0
What do you think should be done?What do you think should be done?Medical OncologistMedical OncologistA. Radical mastectomyB. Modified radical mastectomyC. Referral to medical oncology for
neoadjuvant treatmentD. Referral to radiation oncology for pre-
operative external beam radiationE. Palliative care
Discussion – case summaryDiscussion – case summaryMammogram right breast normal6x8cm mass left breast – highly suspicious for
malignancy BIRAD 5Pathology reports infiltrating ductal carcinoma, high
gradeER, PR negative, Her2-neu not amplified (Triple
negative)Staging studies negativeClinical Stage: T3 N2 M0 (Stage III)
Tumor Conference Treatment Plan:Tumor Conference Treatment Plan:Neoadjuvant treatment
Salvage mastectomy
External radiation therapy
Suppressive endocrine therapy ??
Follow up
Medical Oncologist’s thoughts, goalsMedical Oncologist’s thoughts, goals
Healthy 52 year old woman with locally advanced breast cancer, triple negative, disease still seems localized to the breast and axilla.
Neoadjuvant treatment (chemotherapy prior to surgery) will reduce tumor size and allow a mastectomy or perhaps a lumpectomy in selected cases.
In Fact post AC4 +T4 tumour size went down to 2x2 cm.
T1yNxMx.
Medical Oncologist’s thoughtsMedical Oncologist’s thoughtsMS does not qualify for post-operative
endocrine therapy (Tamoxifen or aromatase inhibitors) because as her tumor was ER/PR negative
She does not qualify for anti-HER2-neu therapy as her tumor was HER2 negative.
Survival According to Treatment: Stage IIISurvival According to Treatment: Stage III
Treatment No. of Patients
5-Year Survival
Surgery only 2,453 36%
Radiation only 2,386 29%
Surgery plus radiation 4,249 33%
Chemotherapy, Surgery, and Radiation 1,923 63%
Giordiano SH. Oncologist. 2003;8:521-530.