BREAST CANCER

Robert Miller MDwww.aboutcancer.com

Decisions that need to be made about treating breast cancer

NCCN.org

Treatment Decisions

1. Surgery: mastectomy versus conservation (lumpectomy)

2. Adjuvant Therapy: hormone therapy, chemotherapy, targeted therapy

3. Radiation: whole breast or partial breast (balloon)

Treatment Decisions

The woman should be assisted by a multi-disciplinary team, including a surgeon, possibly a plastic surgeon, medical oncologist and a radiation oncologist

Woman with lumpectomy.A dark area indicates tumorB light pink highlighted area indicates tissue removed at lumpectomy

Woman with modified radical mastectomy.A pink highlighted area indicates tissue removed at mastectomyB axillary lymph nodes: levels IC axillary lymph nodes: levels IID axillary lymph nodes: levels III

Deciding on Surgery

Operable Breast Cancer: In Defense of Conservative SurgeryCA: A Cancer Journal for Clinicians

Volume 23:November/December 1973. George Crile Jr.

Survival Comparisons Between the Cleveland Clinic (no mastectomies) with National Cancer Registry (mastectomies)

Cleveland Clinic virtually abandoned radical mastectomies in 1957

Prospective Randomized Trials Comparing Conservation Surgery with Mastectomy in Early Stage Breast Cancer

Survival Comparisons Between Conservation Surgery (CS) plus Radiation (RT) versus Mastectomy

10 year survival of 112,154 women with stage I/II breast cancer comparing lumpectomy / radiation with mastectomy.

Radiation has a better long term survival than mastectomy

Mastectomy or Lumpectomy

Results of Randomized Trials Comparing Conservation Surgery (CS) With or Without PostOp Radiation (RT)

Reasons to Favor Mastectomy over Conservation/Radiation

Breast Conservation

Lumpectomy (remove the cancer with a small rim of normal tissue, clear margins)

Sentinel node biopsy will often be performed at the same time

Level 1 and 2 Nodes May be Removed, depending on the status of the sentinel node

biopsies

At the time of the lumpectomy the surgeon tries to remove the cancer with a margin of normal breast tissue around the mass

X-ray image of the lumpectomy specimen

Deciding on the necessity and benefits of hormone therapy or chemotherapy

Before radiation, a decision needs to be made about the need for systemic therapy (hormone therapy or chemotherapy)

NCCN.org

Genetic ProfilesMay show that some women with favorable breast cancer (estrogen + and node -) may need more than just Tamoxifen / analyze the cancer for the presence (expression of 21 breast cancer genes)

Genetic ProfilesMay show that some women with favorable breast cancer (estrogen + and node -) may need more than just Tamoxifen

27% of women had a high risk gene profile and 30.5% relapsed after Tamoxifen and they may have done better with chemotherapy

Online Breast Cancer Calculators www.aboutcancer.com

www.adjuvantonline.com

For this elderly woman with a low risk cancer, the benefits from hormone therapy (0.3%) or chemotherapy (0.1%)would be very small and she would probably decide not to take either

Benefits of intensive chemotherapy in a young woman with high risk cancer

For this young woman with high risk cancer, the benefits from chemotherapy would be very large (10 year survival would move from 33.5% to 51%) and she almost always would agree to it

Deciding on Radiation

Then a decision about the need for radiation and how large should the radiation target be

CT scan is obtained at the time of simulation

CT images are then imported into the treatment planning computer. Note that at the time of the simulation the patient may receive 3 small tattoo marks

Computer generated anatomy images that will identify all the important structures to be sure the radiation covers the area of breast cancer and limits the dose to other areas

Viewed from the side, the radiation stops before hitting the lung

Typical technique for external beam

Radiation beam skims over the surface of the chest wall, ribs and luring

If the radiation does not go deep enough the cancer can grow back (the areas in the red)

note: cases are from a textbook and not treated here at Wellspring

Radiation Technique

External Beam Radiation

Monday through Friday for 5 weeks

After a lumpectomy the whole breast is radiated for about 5 weeks (the red box) and then a boost dose (5 – 7 treatments) is given to the lumpectomy site (blue circle)

Radiation

Fields

Sometimes along with radiation to the breast, the high nodes in the neck (supraclavicular nodes) may be treated (the NCCN guidelines recommend these nodes be treated if there was cancer in the axilla)

The whole breast treated 26 to 28 times

The lumpectomy site is then treated 5 to 7 times

Whole breast treated with X-rays from side to side, and skims the surface of the lung or pleura

Phase 1 External Beam Radiation (X-rays)

lumpectomy

Lymph node

Phase 2 External Beam Radiation (electron beam)

Electron beam is used to target straight on the area of the lumpectomy (and the radiation does not penetrate deeply)

lumpectomy

Generally the side effects of breast radiation do not become noticeable until the woman has received about 10 to 15 treatments, and then become somewhat more noticeable through the rest of the treatment. The most common side effects:

•skin irritation - the skin that is radiated gets red, itchy and may blister (like a sun burn) may lose hair in arm pit (biafine, prutect, myaderm, aquaphor, silvadene, triamcinalone, Radiaderm)

•breast or chest wall tenderness or mild pain

•tiredness or fatigue (some women feel a little light-headed)

•are swelling or edema

Short Term Side Effects of Breast Radiation  

By 2 to 3 weeks the skin burn has healed up almost completely

Long Term Side Effects of Breast Radiation

• Arm swelling or lymphedema is probably less than 3%

• Lung inflammation (pneumonitis) is 5% or less• Risk of rib fracture is less than 3%• Risk of nerve damage (brachial plexopathy) < 1%• Radiation fibrosis to breast• Risk of causing a new cancer is less than 1%

BREAST CANCER

Robert Miller MDwww.aboutcancer.com