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BIOLOGICAL PRINCIPLES OF BIOLOGICAL PRINCIPLES OF BREAST CANCER TREAMENTBREAST CANCER TREAMENT
Benjamin O. Anderson, M.D.Director, Breast Health Clinic
Professor of Surgery and Global Health, University of WashingtonJoint Member, Fred Hutchinson Cancer Research Center
Seattle, Washington
U .W .S .O .M . F.H.C.R.C.
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BIOLOGICAL BASIS OF TREATMENTBIOLOGICAL BASIS OF TREATMENTOutlineOutline
Breast cancer surgery
Breast radiation therapy
Systemic (drug) therapy
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BIOLOGICAL BASIS OF TREATMENTBIOLOGICAL BASIS OF TREATMENTOutlineOutline
Breast cancer surgery
Breast radiation therapy
Systemic (drug) therapy
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RADICAL MASTECTOMYRADICAL MASTECTOMY MODIFIED RADICAL MASTECTOMYMODIFIED RADICAL MASTECTOMY
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EVOLUTION IN CANCER TREATMENTEVOLUTION IN CANCER TREATMENT
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BREAST CONSERVATION:BREAST CONSERVATION:Long-term validationLong-term validation
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NSABP B-06:NSABP B-06:Effect of Lumpectomy v. Mastectomy on RecurrenceEffect of Lumpectomy v. Mastectomy on Recurrence
CU
MU
LA
TIV
E I
NC
IDE
NC
E
All Patients Node Negative Node Positive
Lumpectomy LumpectomyLumpectomy
Lumpectomy + radiation Lumpectomy + radiationLumpectomy + radiation
Lumpectomy: 570/210 361/121 209/89
Lumpectomy + XRT: 567/62 375/50 192/12
No. of patients / No. of recurrences
YEAR
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NSABP B-06:NSABP B-06:Effect of Lumpectomy v. Mastectomy on SurvivalEffect of Lumpectomy v. Mastectomy on Survival
DIS
TA
NT
DIS
EA
SE
-FR
EE
SU
RV
IVA
L (
%) Cohort A Cohort B Cohort C
Total Mastectomy: 692/265 569/233 494/192
Lumpectomy: 699/302 634/282 520/236
No. of patients / No. of recurrences
YEAR
Lumpectomy + XRT: 714/278 628/253 515/204
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SURGICAL MARGINS:SURGICAL MARGINS:Surgical PrinciplesSurgical Principles
Cancers must be removed with NEGATIVE
MARGINS for adequate local treatment
Some cancers can be removed with negative
margins with a partial mastectomy
Other cancers require mastectomy for complete
removal with negative margins
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BIOLOGICAL BASIS OF TREATMENTBIOLOGICAL BASIS OF TREATMENTOutlineOutline
Breast cancer surgery
Breast radiation therapy
Systemic (drug) therapy
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BIOLOGICAL BASIS OF TREATMENTBIOLOGICAL BASIS OF TREATMENTOutlineOutline
Breast cancer surgery
Breast radiation therapy
Systemic (drug) therapy
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BREAST CONSERVING SURGERYBREAST CONSERVING SURGERY
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BREAST CONSERVING RADIATION THERAPYBREAST CONSERVING RADIATION THERAPY
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BREAST CONSERVATION:BREAST CONSERVATION:Radiation Therapy ConceptsRadiation Therapy Concepts
Surgical lumpectomy: removes tumor bulk
Radiation therapy after surgery: eradicates residual
microscopic cancer
POSTOPERATIVE RADIATION TREATMENT
DECREASES LOCAL RECURRENCE RISK OF
BREAST CANCER FROM 30-40% to 10%
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BIOLOGICAL BASIS OF TREATMENTBIOLOGICAL BASIS OF TREATMENTOutlineOutline
Breast cancer surgery
Breast radiation therapy
Systemic (drug) therapy
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BIOLOGICAL BASIS OF TREATMENTBIOLOGICAL BASIS OF TREATMENTOutlineOutline
Breast cancer surgery
Breast radiation therapy
Systemic (drug) therapy
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AXILLARY NODE DISSECTION:AXILLARY NODE DISSECTION:Complication RatesComplication Rates
Lymphedema– Acute: 40%
– Chronic: 15-20%
Paraesthesia: 40%
Need for a drain: 100%
Seroma formation: 10%
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SENTINEL NODE CONCEPTSENTINEL NODE CONCEPT
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BREAST CANCER TREATMENT:BREAST CANCER TREATMENT:Adjuvant Systemic TherapyAdjuvant Systemic Therapy
Chemotherapy or hormonal therapy used after operation
Improves survival rates beyond operation alone
Used for node-positive and some node-negative invasive cancers
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NEOADJUVANT CHEMOTHERAPY: NEOADJUVANT CHEMOTHERAPY: DefinitionDefinition
Preoperative systemic chemotherapy intentionally administered prior to
definitive surgical resection
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NEOADJUVANT CHEMOTHERAPY: NEOADJUVANT CHEMOTHERAPY: NSABP B-18 - OperableNSABP B-18 - Operable
1,523 randomized: AC / preop vs. postop No difference in DFS or OS at 5 years
cCR / m CR / pCR correlated with outcome
Increased Lumpectomy / XRT after NCT
(67.8% vs 59.8%, p < 0.05)
Similar local recurrence after lumpectomy
(7.9% vs 5.8%, p = .23)
Fisher, J Clin Oncol 16:2672, 1998Fisher, J Clin Oncol 16:2672, 1998
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NEOADJUVANT THERAPYNEOADJUVANT THERAPYCategories of Breast Cancer
Inflammatory breast cancer– Stage III B
Locally advanced breast cancer– Stage III non-inflammatory: – T3 / clinN1-2
“Operable” breast cancer– Stage II B: T3N0, T2 (borderline BCT)
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NEOADJUVANT THERAPYNEOADJUVANT THERAPYRationale
Inflammatory breast cancer– Convert inoperable to marginally operable
Locally advanced breast cancer– Convert marginally operable to resectable
“Operable” breast cancer– Improve breast conservation rates
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PRIMARY NEOADJUVANT RESPONSEPRIMARY NEOADJUVANT RESPONSEUtility of Breast MRI for Following Drug Response
Partridge AJR 2005;184:1774
Pre-treatment – 22 cm3 One Cycle 30% Decrease
Four Cycles88% decrease
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CONCLUSIONSCONCLUSIONS Breast surgery removes the primary disease in the breast and
provides staging information to determine adjuvant treatment.
Radiation therapy allows for conservation of the breast (as opposed to mastectomy) in properly selected patients.
Systemic (drug) treatment is critical for improving mortality and is not replaced by more extensive local therapy.
Multidisciplinary collaboration is the heart and soul of breast cancer treatment and is required to improve patient outcome.
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F.H.C.R.C.
UNIVERSITY OF WASHINGTONUNIVERSITY OF WASHINGTON
FRED HUTCHINSON CANCER CENTERFRED HUTCHINSON CANCER CENTER
CHILDREN’S HOSPITALCHILDREN’S HOSPITAL
SEATTLE CANCER CARE ALLIANCESEATTLE CANCER CARE ALLIANCE
UNIVERSITY OF WASHINGTONUNIVERSITY OF WASHINGTON
FRED HUTCHINSON CANCER CENTERFRED HUTCHINSON CANCER CENTER