Myriad Speaker’s Bureau (not•o oncoplastic techniques Preventing cancer ... prepared to discuss...
Transcript of Myriad Speaker’s Bureau (not•o oncoplastic techniques Preventing cancer ... prepared to discuss...
•Myriad Speaker’s Bureau (not
today)
o I have given lectures and met with health
care providers in other states (Missouri,
Minnesota, Nebraska, Colorado, Oklahoma)
to educate physicians about the risk factors
for BRCA.
oThis is NOT sponsored by Myriad and
should represent an unbiased presentation
of regional testing data (although
incomplete- not all data was released).
Disclosure
• Presentation of breast cancer
• Changes in treatmento surgical approach to breast cancer.....
o chemotherapy indications
o oncoplastic techniques
• Preventing cancer o “previvors”
o Therese Cusick, MD FACS
Breast Cancer Update
Obvious vs.
Subtle
many different presentations....
PAGET’S DISEASE
Scaly nipple
Left
MLO
How a cancer
SHOULD
present...
• 0- Incomplete
• 1- Without lesion
• 2- Benign lesion
• 3- Lesion of low suspicion
• 4- Moderately suspicious lesion
• 5- Highly suspicious lesion
BI-RADS
Left
MLO
Breast MR
• Used to prove uni-focal disease
• Lobular breast cancero Multifocal
o Increased incidence of bilaterality
o Difficult to visualize with mammography
o Vague physical exam
• Dense Mammogramso Young patients
o Occasionally older pts with dense
mammos
(look at cancer on the mammogram)
Dense breast
Solitary mass with no other
abnormality
Diagnosis of Breast
Cancer-2010• Breast Cancer diagnosis should be
made by a core bx, NOT OPEN BX IN
OR!
• Allows for pre-planning, oncoplastic
techniques, improved SLN
• Does everyone need a core pre-
operatively?o If one suspects cancer, yes (unless
advanced age)
o If pt desires excision of a lesion thought
highly likely to be benign, no
CHEMOTHERAPY
Changes in
treatment…• Chemotherapy decisions are no
longer based on size of tumor and
lymph node status alone…
• Individualized to the patient!
• Tumor BIOLOGY…
Oncotype DX™ 21-Gene Recurrence Score (RS) Assay
PROLIFERATION
Ki-67
STK15
Survivin
Cyclin B1
MYBL2
ESTROGEN
ER
PR
Bcl2
SCUBE2
INVASION
Stromelysin 3
Cathepsin L2
HER2
GRB7
HER2
BAG1GSTM1
REFERENCE
Beta-actin
GAPDH
RPLPO
GUS
TFRC
CD68
16 Cancer and 5 Reference Genes From 3 Studies
Category RS (0-100)
Low risk RS <18
Int risk RS ≥18 and <31
High risk RS ≥31
RS = + 0.47 x HER2 Group Score
- 0.34 x ER Group Score
+ 1.04 x Proliferation Group Score
+ 0.10 x Invasion Group Score
+ 0.05 x CD68
- 0.08 x GSTM1
- 0.07 x BAG1
Pre-Operative
Chemotherapy• Neo-adjuvant Chemotherapy
o Inflammatory Breast Cancer
-Chemo, mastectomy, radiation
o Large tumors in an attempt to close with
mastectomy
o Large tumors in an attempt to proceed with
breast conservation
-Note that not all cancers shrink concentrically
•Smaller vs. the “swiss cheese” effect
-Must place a tumor marker!!!
o Node Positive Patients
-Enlarged nodes noted at time of dx, FNA+
o Suspected BRCA
-Allows additional time for testing to return
Improvements
• Radical Mastectomy
• Modified Radical Mastectomy
• Lumpectomy and axillary node
dissection
• SENTINEL LYMPH NODEo Mastectomy or lumpectomy
• Oncoplastic surgeryo Lumpectomy with local tissue rearrangement
o Reduction lumpectomy
o Skin and nipple sparing mastectomies
Is lumpectomy a step up from mastectomy?left= mastectomy and reconstruction Right= bad lumpectomy deformity
London-Royal College
of Surgeons
• A woman had to “prove herself
worthy” of reconstruction by living 5
years without a breast (due to the
shortage of plastic surgeons in
England).
Oncoplastics
• Combining plastic surgery and breast
cancer surgery
• Preplanning required
• Team approach with plastic surgeon
• Some cases-cancer surgeon only
Cancer vs. Cosmesis
Nipple Sparing
Peau de orange
Previous Incision
Nipple SparingNipple
Sparing
Mastectomy
Specimen
Nipple
Before
mastectomy
(left)
After
Mastectomy
(right)
Mastectomy with reconstruction
Post-Mastectomy
Radiation• Classic Indications
o Tumor larger than 5 cm
o 4 or more +LN
o Involved margins/Chest wall
o Inflammatory Breast Cancer
• Possible Indicationso 1-3 + nodes in pre-monepausal pt
Post-Mastectomy
Radiation
• Attempt to predict preoperatively who
will need post-mastectomy radiationo Not ideal to radiate muscle flaps
-TRAM flaps
-Latissimus flaps
-These flaps may be used to reconstruct AFTER
radiation
o OK to radiate tissue expanders
-Deflate
-Place implant (5th generation) vs. flap
2006 ASCO Recommendations
(Von Wald)
“As part of education and informed consent prior to cancer
therapy, oncologists should address the possibility of infertility
with patients treated during their reproductive years and be
prepared to discuss possible fertility preservation options or
refer appropriate and interested patients to reproductive
specialists. Clinician judgment should be employed in the
timing of raising this issue, but discussion at the earliest
possible opportunity is encouraged. Sperm and embryo
cryopreservation are considered standard practice and widely
available; other available fertility preservation methods should
be considered investigational and be performed in centers
with the necessary expertise.Lee SJ, et al. J Clin Oncol 2006;24(18):1-16
BRCA
• >80% lifetime risk of breast cancer
• Up to 44% risk of ovarian cancer
• 64% chance of second breast cancer
• Red flagso Breast cancer <age 50
o Breast and ovarian cancer
o Male breast cancer
Young
◦ Age < 45
Young and Multiple
◦ Age <50
◦ At least 2 cancers (young breast,
ovarian)
Multiple
◦ 3 total cancers regardless of age
Combination of breast and ovarian
(male breast cancer counts as 2)
Testing Criteria 1,2,3
Bilateral mastectomies with
reconstruction vs.
Annual MRI alternating with annual
mammography (q 6 months)
Second breast cancer
◦ Ipsilateral vs. contralateral breast
◦ Tissue is radiated….
Prevent second breast cancers in our pts
Prevent ovarian cancers in our pts
Select appropriate surgeries for our
newly diagnosed pts
Identify families so we can prevent these
cancers in their family members
Surgeon Testing
If you believe that 20% of breast cancer
patients are appropriate for testing, we are
now improving our numbers to come closer
to that estimate.
Those states that exceed the 20% rule, are
likely capturing past cancer patients that
were not previously tested.
Have we truly only identified 10% of BRCA
carriers?
Average #
Cancers/Yr
Average #
BRCA/Yr
% affected
tested
Missouri 4824 546 11.31%
Oklahoma 2960 149 5.03%
Arkansas 2180 126 5.77%
Kansas 1890 304 16.08%
Nebraska 1224 187 15.27%
2003-2008
Recent tests by specialty
(5 state area)
81
GENETICIST, MD
KANSAS
2008 BREAST CANCER
%TESTED
46 year old patient was diagnosed with
breast cancer at the age of 33.
◦ Opted for bilateral mastectomies and
reconstruction.
◦ Family hx
Maternal great aunt with ovarian CA
Maternal great grandmother with breast
cancer
◦ Pt recently diagnosed with Stage 3
ovarian cancer
◦ Criterion for testing?
29 year old, newly diagnosed 3 cm
breast cancer
◦ Neoadjuvant chemotherapy?
◦ Lumpectomy and radiation?
◦ Mastectomy and reconstruction?
◦ Bilateral mastectomies with
reconstruction?
◦ Oophorectomy?
ovaries?
Timing of oophorectomy
important if placing
mesh....
www.facingourrisk.org
www.bebrightpink.org
Thank you! QUESTIONS?