Update on Breast Care

M. Bernadette Ryan, M.D., FACSHead, Section of Surgical Oncology

May 18, 2009

Outline

ANDI concept in benign breast disease myatalgia

Breast imaging for screening & diagnosis

Breast Cancer 1/2009 update in NCCN guidelines PBI Oncotype Dx

ANDI

Aberrations of normal development and involution

concept of benign disorders based on pathogenesis

First published by Hughes et al. in 1987 in Lancet

Embraced slowly in the USA

ANDI - 2

Bi-directional frameworkHorizontal axis: main clinical

presentation normal - aberration - disease

Vertical axis: stages in development early reproductive (15-25 years) mature reproductive (25-40 years) involution (35-55 years)

ANDI - 3

Normal Process Aberration Disease

EarlyReproductive15-25 years

Lobular developmentStromal developmentNipple eversion

FibroadenomaAdolescent hyperplasiaNipple inversion

Giant FA or multiple FAsGigantomastiaSubareolar abscess/ mammary duct fistula

MatureReproductive25-40 years

Cyclic changes

Epithelia hyperplasia of pregnancy

Cyclic mastalgiaNodularityDuctal papilloma

Bloody nipple discharge

Incapacitating mastalgia

Involution35-55 years

Lobular involution microcystsDuct involution dilation sclerosisEpithelial turnover

Macrocysts, adenosis, sclerosing lesions

Ductal ectasiaNipple inversionHyperplasia

Periductal mastitis/ abscessAtypia

Non - ANDI

Fat necrosisLactational abscessesContributions of smoking and oro-nipple

contact in non-puerperal abscessesTrue neoplasms: phyllodes tumor,

tubular adenoma, lipoma, etc.Mondor’s disease, diabetic mastopathy,

…

Mastalgia

Probably hormonally related usually cyclic and ends with menopause responds to hormone treatment

Many theories: increased estrogen decreased progesterone increased prolactin increased end-organ response low prostaglandin E1 due to EFA deficiency

Mastalgia - 2

Cyclic or non-cyclic breast pain rule out chest wall source in non-cyclic rule out significant lesion with imaging

localized pain may be due to cancer, cyst, sclerosing lesion

Treatment Reassurance if mild Reassurance and primrose oil if moderate Add drugs if severe (interferes with lifestyle)

Mastalgia - 3

Cyclic Pain Non-Cyclic

Primrose oil1000-1500 BID

44-58% 27%

Danazol200-400 mg QD

70-80% 30%

Tamoxifen10 mg QD

80-90% 56%

Bromocriptine2.5 mg BID

47% 20%

Placebo 10-40% 10-40%

Breast Imaging

MammogramsUltrasoundMRIPET scans

Mammograms

Annual screening beginning at age 40 as young as 25 in high risk groups upper limit not established

Digital mammogram may be better especially in young women and older women with dense breasts

Mobile units may increase compliance

Ultrasound

Initial diagnostic tool in women < 30-35 with symptoms or palpable findings

Adjunct to mammography diagnostic w/u biopsy

May be used with mammogram to screen women at high risk or with dense breasts no PRS showing survival benefit

MRI - screening

Screen high risk women BRCA 1 or 2, TB53 or PTEN mutations First degree relative with above & untested Lifetime risk 20-25% by model based on FHx Chest irradiation between ages 10 & 30

Role in women at lesser risk uncertain LCIS, AH, prior breast cancer, 15-20% risk

Not recommended in average risk women

BRCAPRO

Free programs availableNeed extensive family history

age of diagnosis of cancer as well as current age or age of death of relatives

Calculates risk of harboring BrCa gene and risk of developing breast & ovarian cancer

BRCAPRO - 2

BRCAPRO - 3

BRCAPRO - 4

MRI - diagnostic

Define extent of disease before BCS leads to higher mastectomy rate without

clear benefit in local control or survivalDefine extent of disease before & after

neoadjuvant therapy Look for additional primariesLook for occult primary

Paget’s disease & isolated nodal metastases

PET scan

NCCN recommends against use in stage I-III disease “Biopsy of equivocal or suspicious sites is

more likely to provide useful information”Lobular cancer frequently PET negativeNot useful to stage axillaoverall role in breast cancer unclear

NCCN updates: DCIS

Minimum margin is still 1 mm generally decreased failure rates with wider

margins up to 10 mm post-excision mammogram if uncertainty

Recommends against sentinel node biopsy reasonable for mastectomy

Excision alone in “low” risk disease radiation reduces local failure by 50% equivalent survival

NCCN: invasive cancer w/u

Genetic counseling if high riskMRI optionalNo PET or PET/CTER/PR and Her 2: use a reliable labImaging to rule out metastases only if

symptomatic may consider in locally advanced disease

NCCN - local treatment

Negative margin not definedFocally + margin acceptable if no EIC

consider higher XRT boost to tumor bed> 70, T1N0M0, ER/PR +

reasonable to treat with lumpectomy & tamoxifen or an aromatase inhibitor

can be cN0 or pN0

NCCN - neoadjuvant

In Stage II & T3N1: only if pt wants BCSUse in all other Stage IIIConsider AI if post-menopausal & ER/PR

positivecN+: confirm with needle biopsy

Level I & II dissection regardless of responsecN-: SNBx pre- or post-chemo

AxD if +

NCCN - Radiation

Radiation can be with or without a boost boost: < 50, close margins, + nodes or LVI

PBI discouraged outside of a trial Post-mastectomy XRT unchanged:

>/= 4 + nodes, >5 cm, margins < 1mm or + consider in 1-3 nodes

Base XRT on initial clinical stage in neoadjuvant patients

Partial Breast Irradiation

Low risk women age > 45, tumor </= 3 cm, negative

margins & nodes (? DCIS)Potential advantages

shorter treatment course can give prior to chemotherapy may improve access to BCS

? better cosmesis Need PRTs to compare failure rates

PBI - 2

Treat tumor bed with 1 cm marginsIntra-op: single fractionPost-op:

BID x 10 fractions with total dose 34-38.5 GyMammoSite and other balloonsafter loading cathetersexternal beam with 3D conformal/IMRT

NCCN - adjuvant treatment

ER/PR + & Her 2 -: consider OncotypeStill little data on chemo in women > 70

individualize considering co-morbiditiesNo prospective randomized data on use

of Herceptin in tumors < 1 cm & node - but considered reasonable

Baseline & f/u DEXA scans if treat with AI or if menopause induced by treatment

T1/2, ER/PR+, node -, her 2-

adjuvantonline age, health, size, grade, nodes, ER/PR odds of death or recurrence at 10 years odds of benefit from adjuvant treatment

Oncotype Dx 21 gene test on paraffin blocks recurrence score: correlates with 10-year

relapse in tamoxifen-treated patients and with benefit from chemotherapy

Tailor X

PRT to determine value of OncotypeLow RS (1-10): tamoxifen or AIHigh RS (> 26): chemotherapy and

tamoxifen or AIIntermediate RS (11-25): randomize

between 2 treatments above Off study, 18-30 considered intermediate

about $3000 (some insurances cover test)

Future

Greater effort to tailor treatment to individual to avoid toxicity without jeopardizing survival

Pay for performance accredited breast centers adherence to national guidelines volume of breast cases

Comments or questions?