Breast Cancer in 2012Breast Cancer in 2012

Jane Carleton, M.D.Jane Carleton, M.D.

Monter Cancer CenterMonter Cancer Center

North Shore-LIJNorth Shore-LIJ

Breast Cancer in the U.S.Breast Cancer in the U.S.

1 in 8 women in the U.S. will be diagnosed 1 in 8 women in the U.S. will be diagnosed with breast cancer in their lifetimewith breast cancer in their lifetime

Hereditary vs. environmental causesHereditary vs. environmental causes Higher incidence of breast cancer in Higher incidence of breast cancer in

industrial areas, including most of the east industrial areas, including most of the east coast, west coast and around the great coast, west coast and around the great lakeslakes

Is NYC or Long Island a hot spot?Is NYC or Long Island a hot spot?

Hereditary Causes of Breast CancerHereditary Causes of Breast Cancer

BRCA1 and BRCA2BRCA1 and BRCA2 Increased risk of breast and ovarian cancerIncreased risk of breast and ovarian cancer Only found in ~5% of breast cancer patientsOnly found in ~5% of breast cancer patients More common in certain groups such as More common in certain groups such as

Ashkenazi Jewish populationAshkenazi Jewish population Only about 15% of breast cancer is clearly Only about 15% of breast cancer is clearly

linked with a strong family history and linked with a strong family history and possible inherited risk factorpossible inherited risk factor

Screening for Breast CAScreening for Breast CA

Annual mammogramAnnual mammogram Starting at 40 or 50?Starting at 40 or 50? Should it be every other year?Should it be every other year? Current guidelines: start at 40 and every yearCurrent guidelines: start at 40 and every year

Sonogram for patients with dense breast tissue Sonogram for patients with dense breast tissue or for additional evaluation (cyst vs nodule)or for additional evaluation (cyst vs nodule)

MRI only in selected patientsMRI only in selected patients Patients with BRCA mutation starting at 25Patients with BRCA mutation starting at 25 Patients newly diagnosed with breast cancerPatients newly diagnosed with breast cancer

Evaluating a NoduleEvaluating a Nodule

A needle biopsy is the preferred method to A needle biopsy is the preferred method to evaluate an abnormality found on mammogram evaluate an abnormality found on mammogram or sonogramor sonogram

Needle biopsies are usually done by the Needle biopsies are usually done by the radiologist as an outpatient and only require radiologist as an outpatient and only require local anesthesialocal anesthesia

The majority of biopsies are benignThe majority of biopsies are benign Surgical biopsies should only be done when Surgical biopsies should only be done when

further evaluation or treatment is requiredfurther evaluation or treatment is required

Multidisciplinary Teams for Breast Multidisciplinary Teams for Breast Cancer TreatmentCancer Treatment

RadiologistRadiologist Breast SurgeonBreast Surgeon Medical OncologistMedical Oncologist Radiation OncologistRadiation Oncologist Genetics CounselorGenetics Counselor

Surgery for Breast CancerSurgery for Breast Cancer

Lumpectomy vs mastectomyLumpectomy vs mastectomy Sentinel lymph node evaluationSentinel lymph node evaluation

Only a few key lymph nodes removedOnly a few key lymph nodes removed Axillary lymph node dissectionAxillary lymph node dissection

Done when a sentinel lymph node is positive Done when a sentinel lymph node is positive or if suspicious lymph nodes are seen or felt or if suspicious lymph nodes are seen or felt prior to surgeryprior to surgery

Reconstructive SurgeryReconstructive Surgery

By law must be offered and covered by By law must be offered and covered by insurance for women having a mastectomyinsurance for women having a mastectomy

Reconstructive surgery is done by a plastic Reconstructive surgery is done by a plastic surgeon working with the breast surgeonsurgeon working with the breast surgeon

Can be done at the same time as mastectomyCan be done at the same time as mastectomy ImplantsImplants

With or without lattisimus muscle flap With or without lattisimus muscle flap Autologous tissue recreating breastsAutologous tissue recreating breasts

DIEP FlapDIEP Flap Tram FlapTram Flap

PathologyPathology

The biopsy and the surgery give us critical The biopsy and the surgery give us critical information about the tumorinformation about the tumor

Is the tumor sensitive to hormonesIs the tumor sensitive to hormones Estrogen receptorsEstrogen receptors Progesterone receptorsProgesterone receptors

Her-2/neu Her-2/neu About 15-20% of breast cancer have this proteinAbout 15-20% of breast cancer have this protein

Triple NegativeTriple Negative ER negative, PR negative, Her-2/neu negativeER negative, PR negative, Her-2/neu negative

Lymph node statusLymph node status

Breast Cancer StagingBreast Cancer Staging

Stage 0: noninvasive cancer (DCIS)Stage 0: noninvasive cancer (DCIS) Stage I: tumor is <2 cmStage I: tumor is <2 cm Stage II: tumor is larger than 2 cm and/or Stage II: tumor is larger than 2 cm and/or

there are 1-3 lymph nodes involvedthere are 1-3 lymph nodes involved Stage III: tumor is more extensive and/or Stage III: tumor is more extensive and/or

more lymph nodes are involvedmore lymph nodes are involved Stage IV: the tumor has spread to distant Stage IV: the tumor has spread to distant

lymph nodes or organs lymph nodes or organs

Why is Stage Important?Why is Stage Important?

Early stage breast cancer may only need Early stage breast cancer may only need hormonal treatmenthormonal treatment

Lymph node involvement generally means Lymph node involvement generally means chemotherapy should be givenchemotherapy should be given

Larger tumors may need radiationLarger tumors may need radiation Is the treatment goal curative or palliativeIs the treatment goal curative or palliative

Stages 0-III goal is curative Stages 0-III goal is curative Stage IV cancer is not curable but is treatableStage IV cancer is not curable but is treatable

Radiology Imaging Studies to Radiology Imaging Studies to Determine Extent of CancerDetermine Extent of Cancer

Chest XrayChest Xray Bone scanBone scan CT scan of chest, abdomen and pelvisCT scan of chest, abdomen and pelvis CT or MRI of the brain CT or MRI of the brain Pet/CT scanPet/CT scan

Treatment for Breast CancerTreatment for Breast Cancer

Hormonal TherapyHormonal Therapy Offered when tumor is hormone sensitiveOffered when tumor is hormone sensitive

ChemotherapyChemotherapy Important to individualize who really needs itImportant to individualize who really needs it

Targeted TherapyTargeted Therapy Her-2/neu positive breast cancerHer-2/neu positive breast cancer

Hormonal TherapyHormonal Therapy

Breast tumors have receptors for estrogen and/or Breast tumors have receptors for estrogen and/or progesterone 85% of the timeprogesterone 85% of the time

Tamoxifen Tamoxifen Blocks the estrogen receptorBlocks the estrogen receptor Works in both premenopausal and postmenopausal women Works in both premenopausal and postmenopausal women

and in men and in men Aromatase inhibitorsAromatase inhibitors

Anastrazole (Arimidex) Anastrazole (Arimidex) Letrozole (Femara)Letrozole (Femara) Exemestane (Aromasin) Exemestane (Aromasin) These medicines lower estrogen levels in post-menopausal These medicines lower estrogen levels in post-menopausal

womenwomen

TamoxifenTamoxifen

Used for 40 yearsUsed for 40 years Lowers chance of breast cancer Lowers chance of breast cancer

recurrence by ~50%recurrence by ~50% Generally well toleratedGenerally well tolerated Side effects include hot flashes, changes Side effects include hot flashes, changes

in periods, vaginal dryness or dischargein periods, vaginal dryness or discharge Risks include cataracts, blood clots Risks include cataracts, blood clots

(DVT/PE), stroke, endometrial cancer, (DVT/PE), stroke, endometrial cancer, uterine sarcomauterine sarcoma

Aromatase InhibitorsAromatase Inhibitors

Available since the 1990sAvailable since the 1990s Arimidex was compared to Tamoxifen and Arimidex was compared to Tamoxifen and

shown to be slightly more effective with a shown to be slightly more effective with a better side effect profile (reported in 2002)better side effect profile (reported in 2002)

No blood clots, uterine cancer or cataractsNo blood clots, uterine cancer or cataracts Increased risk of bone loss and fractureIncreased risk of bone loss and fracture Increased risk of joint painIncreased risk of joint pain

Chemotherapy & Hormonal TherapyChemotherapy & Hormonal Therapy

Some patients will get only hormonal Some patients will get only hormonal therapy (patients with smaller, lower risk therapy (patients with smaller, lower risk breast cancers) breast cancers)

Some patients will get only chemotherapy Some patients will get only chemotherapy (estrogen/progesterone negative breast (estrogen/progesterone negative breast cancer)cancer)

Many patients will receive both types of Many patients will receive both types of therapy to maximize the cure ratetherapy to maximize the cure rate

When Do We Use Chemotherapy?When Do We Use Chemotherapy?

Tumor is larger than 1 cm (sometimes)Tumor is larger than 1 cm (sometimes) Lymph nodes are involvedLymph nodes are involved The tumor appears aggressiveThe tumor appears aggressive

Poorly differentiatedPoorly differentiated Negative hormone receptors Negative hormone receptors Her-2/neu positive Her-2/neu positive High Ki-67 (marker of aggression)High Ki-67 (marker of aggression)

The Oncotype DX assay The Oncotype DX assay Evaluates the tumor’s DNAEvaluates the tumor’s DNA Used to determine when chemotherapy will be beneficial Used to determine when chemotherapy will be beneficial Gives a score to predict risk of recurrenceGives a score to predict risk of recurrence

How We Choose Chemotherapy How We Choose Chemotherapy

Chemotherapy has been tested in many Chemotherapy has been tested in many clinical trials and certain drugs have come clinical trials and certain drugs have come to be the mainstay of treatment, including to be the mainstay of treatment, including adriamycin, cytoxan, paclitaxel (Taxol), adriamycin, cytoxan, paclitaxel (Taxol), docetaxel (Taxotere)docetaxel (Taxotere)

Most breast cancer regimens use 2-3 Most breast cancer regimens use 2-3 drugs given over 4-6 cycles (doses)drugs given over 4-6 cycles (doses)

The characteristics of the cancer may The characteristics of the cancer may determine the regimen recommendeddetermine the regimen recommended

Standard Chemotherapy RegimensStandard Chemotherapy Regimens

Taxotere and Cytoxan (4-6 cycles)Taxotere and Cytoxan (4-6 cycles) Adriamycin and Cytoxan (four cycles) Adriamycin and Cytoxan (four cycles)

followed by Taxol (four cycles or 12 wks)followed by Taxol (four cycles or 12 wks) Taxotere, Adriamycin and Cytoxan (6 Taxotere, Adriamycin and Cytoxan (6

cycles)cycles) CMF – Cytoxan, Methotrexate and 5-FUCMF – Cytoxan, Methotrexate and 5-FU

An older less effective regimenAn older less effective regimen

Targeted Therapy: Her-2/neuTargeted Therapy: Her-2/neu

Her-2/neu is a protein that some cancers have Her-2/neu is a protein that some cancers have that can make the cancer more aggressivethat can make the cancer more aggressive

About 15-20% of breast cancers are considered About 15-20% of breast cancers are considered Her-2/neu positiveHer-2/neu positive

Trastuzumab (Herceptin) is a monoclonal Trastuzumab (Herceptin) is a monoclonal antibody that binds to Her-2/neu on the outside antibody that binds to Her-2/neu on the outside of the cellof the cell

Clinical studies showed that patients who were Clinical studies showed that patients who were given Trastuzumab in addition to chemotherapy given Trastuzumab in addition to chemotherapy had a 50% improvement in their cure ratehad a 50% improvement in their cure rate

Who gets Trastuzumab?Who gets Trastuzumab?

Trastuzumab (Herceptin) is indicated for patients Trastuzumab (Herceptin) is indicated for patients who are strongly Her-2/neu positive who are strongly Her-2/neu positive

A national clinical trial will study if patients who A national clinical trial will study if patients who are more weakly positive will benefit from are more weakly positive will benefit from Trastuzumab as well (NSABP B-47)Trastuzumab as well (NSABP B-47)

It may also benefit patients with DCIS when It may also benefit patients with DCIS when given with radiation (NSABP B-43)given with radiation (NSABP B-43)

Other Her-2/neu DrugsOther Her-2/neu Drugs

Lapatinib (pill) that binds to Her-2/neu Lapatinib (pill) that binds to Her-2/neu inside the cellinside the cell

Pertuzumab (Perjeta) FDA approved in Pertuzumab (Perjeta) FDA approved in 2012 to be used with Trastuzumab and 2012 to be used with Trastuzumab and Taxotere in metastatic breast cancer that Taxotere in metastatic breast cancer that has not previously been treatedhas not previously been treated

Other Targeted TherapiesOther Targeted Therapies

Bevacizumab (Avastin)Bevacizumab (Avastin) T-DM1 (Trastuzumab linked to DM1, a T-DM1 (Trastuzumab linked to DM1, a

chemotherapy agent)chemotherapy agent) PARP inhibitors are being developed and PARP inhibitors are being developed and

are currently being studied in clinical trials. are currently being studied in clinical trials. They may play an important role in “triple They may play an important role in “triple negative” breast cancernegative” breast cancer

BevacizumabBevacizumab

Bevacizumab (Avastin) is a monoclonal antibody Bevacizumab (Avastin) is a monoclonal antibody that binds to VEGF (vascular endothelial growth that binds to VEGF (vascular endothelial growth factor)factor)

The goal is anti-angiogenesis, or to block new The goal is anti-angiogenesis, or to block new blood vessel formationblood vessel formation

The drug is FDA approved for use in The drug is FDA approved for use in combination with chemotherapy for metastatic combination with chemotherapy for metastatic lung cancer and colon cancer and had been lung cancer and colon cancer and had been approved for metastatic breast cancerapproved for metastatic breast cancer

Breast cancer approval rescinded this yearBreast cancer approval rescinded this year

Bevacizumab in Breast CancerBevacizumab in Breast Cancer

FDA approval for breast cancer rescinded when FDA approval for breast cancer rescinded when studies showed that while there was some studies showed that while there was some improvement in the response to chemotherapy improvement in the response to chemotherapy there was no improvement in overall survival, there was no improvement in overall survival, raising the question of how effective the drug raising the question of how effective the drug really isreally is

Further studies need to be done to establish the Further studies need to be done to establish the role of this drug ( e.g. NSABP B-46 for early role of this drug ( e.g. NSABP B-46 for early stage breast cancer comparing TC vs. TAC vs. stage breast cancer comparing TC vs. TAC vs. TC + Bev)TC + Bev)

Radiation TherapyRadiation Therapy

Used for patients who have had a Used for patients who have had a lumpectomy to improve local controllumpectomy to improve local control

Used for patients who have had a Used for patients who have had a mastectomy if the tumor was large or there mastectomy if the tumor was large or there were many lymph nodes involvedwere many lymph nodes involved

Used to treat a local recurrenceUsed to treat a local recurrence Used in metastatic disease to decrease Used in metastatic disease to decrease

pain or symptoms in a particular spotpain or symptoms in a particular spot

Genetic CounselingGenetic Counseling

Recommended for patients newly diagnosed Recommended for patients newly diagnosed with breast cancer if there is a greater than with breast cancer if there is a greater than standard risk of having an inherited gene for standard risk of having an inherited gene for breast cancerbreast cancer Two or more close relatives with breast cancerTwo or more close relatives with breast cancer Any close female relative with ovarian cancerAny close female relative with ovarian cancer Ashkenazi JewishAshkenazi Jewish

Not done routinely as expensive and chance of Not done routinely as expensive and chance of gene is low unless family history is strongly gene is low unless family history is strongly positivepositive

Follow UpFollow Up

Regular doctor appointmentsRegular doctor appointments Medical oncologist (2-4 times a year)Medical oncologist (2-4 times a year) Surgical oncologist (1-2 times a year)Surgical oncologist (1-2 times a year)

Routine blood workRoutine blood work Annual diagnostic mammogramAnnual diagnostic mammogram Annual sonogram if dense breast tissueAnnual sonogram if dense breast tissue Annual breast MRI Annual breast MRI

Often ordered by the breast surgeonsOften ordered by the breast surgeons Not accepted as a routine test on a national levelNot accepted as a routine test on a national level

Where Do We Stand?Where Do We Stand?

85% of all women who are diagnosed with breast 85% of all women who are diagnosed with breast cancer will die from a non cancer related causecancer will die from a non cancer related cause

The incidence of breast cancer has dropped in The incidence of breast cancer has dropped in the last ten years (especially since estrogen the last ten years (especially since estrogen therapy for postmenopausal women no longer therapy for postmenopausal women no longer being offered as standard therapy for years)being offered as standard therapy for years)

More breast cancer is being detected in earlier More breast cancer is being detected in earlier stages, improving the chance of curestages, improving the chance of cure

New drugs continue to be developed which will New drugs continue to be developed which will further improve our success in treating breast further improve our success in treating breast cancercancer