Download Breast cancer management

Breast Cancer
Management
How treatment is planned
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The main treatments for breast cancer are
Surgery
Radiotherapy
Hormone therapy
Chemotherapy
Biological treatments (such as Herceptin)
Factors to be considered are
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Whether patient have menopause
The type of breast cancer
The size of breast tumor
The stage of breast cancer
The grade of cancer cells
The results of tests on breast cancer cells
general health
Surgical therapies
• Breast-conserving surgery
– Lumpectomy: Surgery to remove a tumor (lump)
and a small amount of normal tissue around it
– Partial mastectomy: Surgery to remove the part
of the breast that has cancer and some normal
tissue around it. This procedure is also called a
segmental mastectomy.
Breast conserving surgery
Breast-conserving surgery.
Dotted lines show the area
containing the tumor that is
removed and some of the
lymph nodes
Surgical therapy
• Modified radical mastectomy: Surgery to
remove the whole breast that has cancer,
allowing removal of level one and level two
lymph nodes but not the apical axillary lymph
nodes and preserves chest wall muscles
Modified radical
mastectomy
Modified radical mastectomy. The
dotted line shows where the entire
breast and some lymph nodes are
removed. Part of the chest wall muscle
may also be removed
Surgical therapy
• Total mastectomy: Surgery to remove the
whole breast that has cancer. This procedure
is also called a simple mastectomy. Some of
the lymph nodes under the arm may be
removed for biopsy at the same time as the
breast surgery or after. This is done through a
separate incision
Total (simple) mastectomy
Total (simple) mastectomy. The
dotted line shows where the entire
breast is removed. Some lymph
nodes under the arm may also be
removed
Surgical therapy
• Radical mastectomy: Surgery to remove the
breast that has cancer, chest wall muscles
under the breast, and all of the lymph nodes
under the arm. This procedure is sometimes
called a Halsted radical mastectomy
Breast reconstruction
• If a patient is going to have a mastectomy,
breast reconstruction (surgery to rebuild a
breast’s shape after a mastectomy) may be
considered. Breast reconstruction may be
done at the time of the mastectomy or at a
future time. The reconstructed breast may be
made with the patient’s own (nonbreast)
tissue like TRAM flap or by using implants
filled with saline or silicone gel
Adjuvant therapy
• Adjuvant therapy (treatment given after
surgery to increase the chances of a cure) may
include the following:
• Radiation therapy to the lymph nodes near
the breast and to the chest wall after a
modified radical mastectomy.
• Systemic chemotherapy with or without
hormone therapy.
• Hormone therapy.
Radiation therapy
• is a cancer treatment that uses high-energy xrays or other types of radiation to kill cancer
cells or keep them from growing. There are
two types of radiation therapy. The way the
radiation therapy is given depends on the type
and stage of the cancer being treated.
Radiation therapy
– External radiation
therapy uses a
machine outside the
body to send
radiation toward the
cancer.
• Internal radiation
therapy uses a
radioactive substance
sealed in needles,
seeds, wires, or
catheters that are
placed directly into or
near the cancer.
Chemotherapy
• Chemotherapy is a cancer treatment that uses
drugs to stop the growth of cancer cells, either
by killing the cells or by stopping them from
dividing. When The way the chemotherapy is
given depends on the type and stage of the
cancer being treated.
Chemotherapy
• Before surgery to shrink a tumor down
(neoadjuvant therapy)
• After surgery to reduce the chance of it
spreading or coming back (adjuvant therapy)
• As treatment for breast cancer that has spread
or come back
Treatment after surgery
• The lymph nodes contained breast cancer
cells
• large primary cancer in the breast
• breast cancer cells were high grade (grade 3)
• cancer cells did not test positive for hormone
receptors and so are not likely to respond well
to hormone therapy
The drugs used to treat breast cancer
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Cyclophosphamide
Epirubicin
5-Fluorouracil or 5 FU
Methotrexate
Mitomycin
Mitozantrone (mitoxantrone)
Doxorubicin (Adriamycin)
Docetaxel (Texture)
Chemotherapy
• NICE(National Institute for Health and Clinical
Excellence) guidance recommends that
adjuvant chemotherapy for breast cancer
should consist of 4 to 8 cycles of a
combination of drugs, including an
anthracycline (epirubicin or doxorubicin).
Chemotherapy
• Some of the most common combinations used for
breast cancer are
• CMF - cyclophosphamide, methotrexate and 5-FU
• FEC - epirubicin, cyclophosphamide and 5-FU
• E-CMF - epirubicin, followed by CMF
• AC - doxorubicin (adriamycin) and cyclophosphamide
• MMM - methotrexate, mitozantrone and mitomycin
• MM - methotrexate and mitozantrone
Hormone therapy
• The female hormones oestrogen and
progesterone are naturally produced by the
ovaries before menopause. After the
menopause, oestrogen is made in much
smaller amounts by the adrenal glands. These
hormones affect the growth of some breast
cancer cells.
Hormone therapy
• drugs or treatments that block the effects of
hormones, or lower the levels of oestrogen
and progesterone, can be used as a treatment
for some types of breast cancer.
Hormone therapy
• Before breast surgery
• After breast surgery
• That has spread or come back after it was first
treated
hormone therapy for breast cancer
• Hormone therapy isn't always a suitable
treatment for breast cancer.
• cancer cells can be tested for estrogen
receptors (ER) or progesterone receptors (PR)
Hormone therapy after surgery
• Hormone treatment has been proved to
reduce the risk of breast cancer coming back
• Hormone therapy seems to work best for
women who have oestrogen receptor positive
cancers.
• One advantage of hormone treatments is very
safe to take and although side effects they are
rarely serious.
Types of hormone therapy
• There are several types of hormone drugs
used for primary breast cancer including
• Tamoxifen
• Aromatase inhibitors (eg Arimidex)
• Pituitary downregulators (eg Zoladex
Tamoxifen
• is often given to patients with early stages of
breast cancer
• metastatic breast cancer
• act on cells all over the body and may
increase the chance of developing
endometrial cancer.
• blocks the uptake of estrogen by breast tissue
Tamoxifen
• Tamoxifen has made a major contribution to
the treatment of breast cancer. Research by
the Early Breast Cancer Triallist Collaboration
Group (EBCTCG) has shown that taking
tamoxifen greatly improves survival rates
for women with oestrogen receptor
positive breast cancer
• by 25% reduction in recurrence and 7% in
mortality
Aromatase inhibitors
• Hormone-dependent breast cancer needs
• Aromatase inhibitors decrease the body's
estrogen by blocking an enzyme called
aromatase from turning androgen into
estrogen
Aromatase inhibitors
• For the treatment of early stage breast cancer,
certain aromatase inhibitors may be used as
adjuvant therapy instead of tamoxifen or after
2 or more years of tamoxifen.
• For the treatment of metastatic breast cancer,
aromatase inhibitors are being tested in
clinical trials to compare them to hormone
therapy with tamoxifen.
Switching off the ovaries
• Women who haven't had their menopause
before being diagnosed with breast cancer are
still producing estrogen. treatment to stop
oestrogen production. They call this ovarian
ablation. There are various ways of doing it.
Switching off the ovaries
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Chemotherapy
Surgery to remove ovaries
'LHRH analogue' or 'pituitary down regulator
LHRH stands for 'luteinising hormone releasing
hormone'.) It blocks a hormone in the brain that
stimulates your ovaries to make and release
oestrogen.
• The commonest of these drugs is goserelin
(Zoladex)
Biological therapy
• Monoclonal antibody therapy is a cancer
treatment that uses antibodies made in the
laboratory These antibodies can identify
substances on cancer cells The antibodies
attach to the substances and kill the cancer
cells
Biological therapy
• Trastuzumab (Herceptin) is a monoclonal
antibody that blocks the effects of the growth
factor protein human epidermal growth factor
type 2 receptors HER2, which transmits
growth signals to breast cancer cells. About
one-fourth of patients with breast cancer have
tumors that may be treated with trastuzumab
combined with chemotherapy.
Biological therapy
• NICE recommended Herceptin as a treatment
option for women with HER2 positive early
breast cancer in August 2006. Women who
are suitable for treatment with Herceptin have
it through a drip every 3 weeks for a year
Biological therapy
• guidance says you can have Herceptin for
early breast cancer if
• cancer cells test positive for HER2
• You have completed surgery and
chemotherapy (and sometimes radiotherapy)
Sentinel lymph node biopsy
followed by surgery
• The sentinel lymph node is the first lymph
node to receive lymphatic drainage from a
tumor
• It is the first lymph node the cancer is likely to
spread to from the tumor.
Sentinel lymph node
• A radioactive substance and/or blue dye is
injected near the tumor
• The substance or dye flows through the lymph
ducts to the lymph nodes.
• The first lymph node to receive the substance
or dye is removed.
Sentinel lymph node
• A pathologist views the tissue under a
microscope to look for cancer cells. If cancer
cells are not found, it may not be necessary to
remove more lymph nodes. After the sentinel
lymph node biopsy, the surgeon removes the
tumor (breast-conserving surgery or
mastectomy).
Sentinel lymph nodes
Treatment according the stages
Ductal Carcinoma In Situ (DCIS)
• Treatment of ductal carcinoma in situ (DCIS)
may include the following:
• Breast-conserving surgery and radiation
therapy with or without tamoxifen.
• Total mastectomy with or without tamoxifen.
• Breast-conserving surgery without radiation
therapy.
Lobular Carcinoma In Situ (LCIS)
• Biopsy to diagnose the LCIS followed by regular
examinations and regular mammograms to find
any changes as early as possible. This is referred
to as observation.
• Treatment of lobular carcinoma in situ (LCIS) may
include the following:
• Tamoxifen to reduce the risk of developing breast
cancer.
• Bilateral prophylactic mastectomy. This treatment
choice is sometimes used in women who have a
high risk of getting breast cancer.
Stage I, Stage II, Stage IIIA, and
Operable Stage IIIC Breast Cancer
• Treatment of stage I, stage II, stage IIIA , and
operable stage IIIC breast cancer may include the
following:
• Breast-conserving surgery to remove only the
cancer and some surrounding breast tissue,
followed by lymph node dissection and radiation
therapy.
• Modified radical mastectomy with or without
breast reconstruction surgery.
Stage IIIB and inoperable stage IIIC
breast cancer
• Systemic chemotherapy.
• Systemic chemotherapy followed by surgery
(breast-conserving surgery or total
mastectomy), with lymph node dissection
followed by radiation therapy. Additional
systemic therapy (chemotherapy, hormone
therapy, or both) may be given.
Stage IV and metastatic breast cancer
• Hormone therapy and/or systemic
chemotherapy with or without trastuzumab
(Herceptin).
• Tyrosine kinase inhibitor therapy with
lapatinib combined with capecitabine.
• Radiation therapy and/or surgery for relief of
pain and other symptoms.
New types of treatment are being
tested in clinical trials.
High-dose chemotherapy with stem cell
transplant
• High-dose chemotherapy with stem cell
transplant is a way of giving high doses of
chemotherapy and replacing blood -forming
cells destroyed by the cancer treatment. Stem
cells (immature blood cells) are removed from
the blood or bone marrow of the patient or a
donor and are frozen and stored. After the
chemotherapy is completed, the stored stem
cells are given back to the patient through an
infusion.
High-dose chemotherapy with stem
cell transplant
• Studies have shown that high-dose
chemotherapy followed by stem cell
transplant does not work better than standard
chemotherapy in the treatment of breast
cancer.
Tyrosine kinase inhibitors as
adjuvant therapy
• Tyrosine kinase inhibitors are targeted therapy
drugs that block signals needed for tumors to
grow. Tyrosine kinase inhibitors may be used in
combination with other anticancer drugs as
adjuvant therapy.
Tyrosine kinase inhibitors
• Lapatinib is a tyrosine kinase inhibitor that
blocks the effects of the HER2 protein and
other proteins inside tumor cells. It may be
used to treat patients with HER2-positive
breast cancer that has progressed following
treatment with trastuzumab.
Clinical trials
• . Shorter Course of Radiation Might Be Just
as Effective with Early Breast Cancer
(Posted: 05/23/2000, Updated: 10/14/2008) For some women with early breast cancer, a
shorter, more intense course of radiation
therapy after surgery may be just as effective
as the standard longer course, according to
updated results presented at the 2008 annual
meeting of the American Society for
Therapeutic Radiation and Oncology
Clinical trials
• . Preventive Surgery Can Reduce Cancer Risk
in Women with BRCA Gene Mutations
(Posted: 05/28/2002, Updated: 10/04/2006) Two separate studies in the May 23, 2002,
issue of the New England Journal of Medicine
support the practice of recommending
preventive surgery in women with a genetic
mutation that puts them at high risk of
developing breast and gynecologic cancers.
Clinical trials
• Radiation Therapy Helps Prevent Recurrence
of DCIS After Breast-Conserving Surgery
(Posted: 07/12/2006) - The addition of
radiation therapy to breast-conserving surgery
for ductal carcinoma in situ reduced the risk of
local recurrence by 47 percent, reinforcing the
benefit of radiation therapy for these women,
according to a report published June 26, 2006,
in the online version of the Journal of Clinical
Oncology.
Clinical trials
• . Sentinel Node Biopsy Improves Quality of Life
in Early-Stage Breast Cancer
(Posted: 05/10/2006) - In the May 3, 2006, issue
of the Journal of the National Cancer Institute,
investigators report results from the first
multicenter randomized trial to compare
postoperative quality of life between patients
with early-stage breast cancer who underwent
sentinel node biopsy and those who underwent
standard axillary lymph node clearance.
Clinical trials
• Surgery Alone Not Sufficient for Ductal
Carcinoma in Situ of the Breast
(Posted: 02/22/2006) - Researchers examined
whether some women with ductal carcinoma in
situ (DCIS) can safely be treated with surgery
alone and found that, in the absence of radiation
therapy, the rate of local recurrence was
unacceptably high, according to the March 1,
2006, issue of the Journal of Clinical Oncology.
The prognosis
• The stage of the cancer
• The type of breast cancer.
• Estrogen-receptor and progesterone-receptor levels in
the tumor tissue.
• Whether the cells have high levels of human epidermal
growth factor type 2 receptors.
• How fast the tumor is growing.
• A woman’s age, general health, and menopausal status
(whether a woman is still having menstrual periods).
• Whether the cancer has just been diagnosed or has
recurred (come back).
Thank you