Breast Cancer Journey: A Clinician PerspectiveBreast Cancer Journey: A Clinician Perspective Sunil...
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Breast Cancer Journey: A Clinician Perspective Sunil Verma MD, MSEd, FRCP(C) Chair, Breast Medical Oncology Head, Breast Clinical Trials Medical Oncologist, Sunnybrook Associate Professor, University of Toronto
Transcript of Breast Cancer Journey: A Clinician PerspectiveBreast Cancer Journey: A Clinician Perspective Sunil...
Breast Cancer Journey:A Clinician Perspective
Sunil Verma MD, MSEd, FRCP(C)
Chair, Breast Medical OncologyHead, Breast Clinical Trials
Medical Oncologist, SunnybrookAssociate Professor, University of Toronto
Death rate/100 000 women, age standardised*
LARGE effect on UK/USA breast cancer mortality by combining several MODERATE effects
Further MODERATE effects are still worthwhile and achievable
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UK
*Mean of annual rates in the seven component 5-year age groups.Source: WHO mortality & UN population estimated.
Peto R on behalf of the EBCTCG. SABCS, December 13, 2007; Berry DA et al. NEJM 2005; F. Levi, Annals of Oncol 2006a.
7 independent meta-analysis showed median decline in mortality of 30% (range: 25%-38%) Due to screening: 15% (range: 7%-23%) Due to adjuvant therapy: 19% (range: 12%- 21%)
Breast Cancer Mortality Rate
Breast CancerCanadian Perspective
Basic Principles of Cancer Therapy Local
– Surgery– Radiation
• Use X-rays to kill cancer cells Systemic
– Chemotherapy• Target rapidly dividing cells
– Endocrine Therapy• Anti-estrogen
– Targeted Therapy• Target the key drivers of cancer growth
Progress in the Treatment of Breast Cancer What have we accomplished over the last two
decades?– Better Treatment
• Improved Chemotherapy• Targeted Therapy• Predictive Markers
– Improved Understanding of Breast Cancer biology• Subtypes of Breast Cancer
– Improved Detection and Screening• Recent data is controversial however has not
impacted current guidelines
Breast Cancer Presentation
Early Breast Cancer
Locally AdvancedBreast Cancer
Metastatic Breast Cancer
Early Breast Cancer Treatment Schema
SURGERY
AdjuvantChemotherapy+/-Targeted therapy
AdjuvantRadiation
AdjuvantEndocrine
CMF
No CT19703.6% OS improvement
ANTHRACYCLINES
1980
4.5% OS improvement
TAXANES
2000
6% OS improvement
Adjuvant Chemotherapy treatment and Survival Improvement: Step by Step
CT + TT (trastuzumab)
6% OS improvement
2006
Decision Making in Adjuvant Therapy
Tumour characteristicsT, N, Grade, ER, PgR,
HER2, LVIPatient Characteristics
Age, ComorbiditiesPrior Therapy
Performance Status
Patient PreferenceWork/Family/Self
Clinical Trials,Guidelines
Recent Reports
Molecular Profile
Breast Cancer Phenotypes …Breast Cancer Phenotypes …
All Breast Cancer
ER+65%–75%
HER2+15%–20%
Triple Neg15%
OncotypeOncotype
Early Breast Cancer Treatment Schema
SURGERY
AdjuvantChemotherapy
AdjuvantRadiation
AdjuvantEndocrine
Follow-Up
Improved Long Term Survival
Horner MJ et al (eds). National Cancer Institute. http://seer.cancer.gov/csr/1975_2006. Accessed July 21, 2009.
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Canadian Cancer Statistics 2013
Hewitt M, et al. eds. From Cancer Patient to Cancer Survivor: Lost in Transition.Washington DC; The National Academies Press; 2005.
Living with Breast CancerHealth Care Provider
Treating the consequences of cancer and its
treatments
Recurrence, new cancers, late effects
Recurrence, second cancers, and assessing medical and psychosocial late effects
Interdisciplinary coordination between PCPs and specialists
Spectrum of Potential Side Effects
Hayes DF. N Engl J Med. 2007;356:2505-2513.
Hot flashes/night sweats
Arthralgia/joint symptoms
Sexual dysfunction
Cognitivedysfunction
Depression
Genitourinary symptoms
Other 2nd-malignancy(ie, endometrial cancer)
Chronic fatigue
Cardiovascular effects
Osteoporosis/bone fractures
Early breast cancertreatments including:
Radiation therapyChemotherapy
Monoclonal antibodyHormonal therapy
Weight gain
Symptom/Side-Effect Management
TreatmentTreatment RecoveryRecoveryTransition to the new
Normal
Transition to the new
Normal
Living Beyond Breast Cancer
Living Beyond Breast Cancer
Living with Breast Cancer
TreatmentTreatment RecoveryRecoveryTransition to the new
Normal
Transition to the new
Normal
Living Beyond Breast Cancer
Living Beyond Breast Cancer
Living with Breast Cancer
TreatmentTreatment RecoveryRecoveryTransition to the new
Normal
Transition to the new
Normal
Living Beyond Breast Cancer
Living Beyond Breast Cancer
Living with Breast Cancer
Treatment Related Side EffectsCost of CareSocial/Emotional/Physical DistressFinancial Distress – Time away from work
TreatmentTreatment RecoveryRecoveryTransition to the new
Normal
Transition to the new
Normal
Living Beyond Breast Cancer
Living Beyond Breast Cancer
Living with Breast Cancer
Social/Emotional/Physical DistressFinancial Distress – Time away from work
TreatmentTreatment RecoveryRecoveryTransition to the new
Normal
Transition to the new
Normal
Living Beyond Breast Cancer
Living Beyond Breast Cancer
Living with Breast Cancer
Reassessing and Readjusting to New reality
Early Breast CancerRole of Family Physicians
SURGERY
AdjuvantChemotherapy
AdjuvantRadiation
AdjuvantEndocrine
Follow-Up
Family physicians
Metastatic Breast Cancer
Metastatic Breast Cancer Therapeutic Goals
Improve/Maintain Quality of life and Prolong Survival while maintaining a good risk:benefit ratio
Subtypes of Breast CancerThe Next Generation of Targeted Drugs
Her 2 Positive ER/PR positive
Available Agents - 2012Available Agents - 2012
Anti-Estrogen Anti-Her 2 Untargeted
Tamoxifen Herceptin Chemo
Aromatase Inhibitors Lapatinib
Available Agents - 2014Available Agents - 2014
Hormone Receptor Positive
Her 2 Receptor Positive
Untargeted
Tamoxifen Herceptin Chemo
Aromatase Inhibitors
Everolimus
Lapatinib
Pertuzumab
T-DM1
Chemo
Available Agents - 2015Available Agents - 2015
Hormone Receptor Positive
Her 2 Receptor Positive
Untargeted
Tamoxifen Herceptin Chemo
Aromatase Inhibitors
Everolimus
Palbociclib
Lapatinib
Pertuzumab
T-DM1
? Everolimus
Chemo
Summary• Cancer is a journey• Our role as health care provider is to
ensure that we build a trusting relationship that extends beyond initial diagnosis and treatment
• The patient needs to recognize the steps in the journey and how their needs and options will evolve
• The future remains bright for many of our patients but it is a life long journey
