Download 2013 Annual Report

Exceptional Medicine
PeaceHealth Physicians Journal
n
Volume 6, Number 1, Fall 2013
“A diagnosis of cancer will forever change
a person’s life. Here at the PeaceHealth
Kearney Breast Centers in Vancouver
and Longview, our teams of dedicated
professionals focus on every aspect of care
for women and men with breast cancer.”
— Sheila Lynam, MD
2013 REGIONAL CANCER CENTERS
ANNUAL REPORT
Exceptional
Medicine
Physicians Journal
PeaceHealth Southwest Medical Center (PHSW)
PeaceHealth St. John Medical Center (PHSJ)
Fall 2013
Volume 6, Number 1
PUBLISHING STAFF
Editorial Director
Laurie Christensen, RN
Contributing Editors
Sheila Lynam, MD, FCAP
Dane Moseson, MD
Janet Mendel-Hartvig, MD, PhD
Kelly Smith, MD
Michael Myers, MD
Submission Guidelines
Exceptional Medicine is a free, editorial-reviewed
publication by credentialed Medical Center staff for
regional physicians.
For complete details and submission guidelines,
go to www.swmedicalcenter.org/exceptionalmedicine
or contact the editorial staff
([email protected] or 360-514-3066).
www.swmedicalcenter.org/exceptionalmedicine
Mission Statement
We carry on the healing mission of Jesus Christ by
promoting personal and community health, relieving
pain and suffering, and treating each person in a
loving and caring way.
© Copyright 2013 PeaceHealth Marketing Department,
PO Box 1600, Vancouver, WA 98668
TABLE OF CONTENTS
Fighting Breast Cancer:
Diagnosis, Staging and Treatment
1
Introduction
2
Meet our Teams
5
Who will get Breast Cancer?
7
How is Breast Cancer Diagnosed?
11 What are the Types of Breast Cancer?
18 How is Breast Cancer Treated?
28 What is the Role of Research?
31 What is the PeaceHealth Experience?
32 Conclusion
Fighting Breast Cancer:
Diagnosis, Staging
and Treatment
B
reast cancer is the second leading cause of cancer death in women and
while every woman is at risk to develop breast cancer, there are many factors
that play into that level of risk. In this report, we explore risk factors, detection,
types of breast cancer, pathology, staging and treatment of breast cancer.
Sheila Lynam, MD, FCAP
Pathologist, PHSJ
Dane Moseson, MD
Surgeon, PHSJ
Janet Mendel-Hartvig, MD, PhD
Radiologist, PHSJ
Kelly Smith, MD
Medical Oncologist, PHSW
Michael Myers, MD
Radiation Oncologist, PHSW
Kara Makin-Bond, RN
PHSW
Rhonda Wrolson, CTR
Certified Tumor Registrar, PHSJ
Marie Tesdale, RHIT, CTR
PHSW
Kelly DeRoiser, RN, BSN, CBPN-IC
Nurse Navigator, KBC PHSJ
Ruth Melvin, RT (M)
Clinical Operations Supervisor, KBC, PHSJ
Sherril Allen, RN
Manager, KBC, PHSW
Volume 6, Number 1
Correspondence:
Sheila Lynam, MD
[email protected]
Lower Columbia Pathologists
PO Box 3012
Longview, WA 98632
360-425-5620
www.peacehealth.org
PeaceHealth Southwest Medical Center (PHSW) and
PeaceHealth St. John Medical Center (PHSJ) are referenced
as Lower Columbia Region (LCR) throughout this report.
Exceptional Medicine
1
Meet our Teams
C
ancer Care at PeaceHealth St. John and PeaceHealth Southwest Medical
Centers involves a coordinated approach, utilizing the services of cancer
specialists throughout our medical centers.
KEARNEY BREAST CENTER
PEACEHEALTH ST. JOHN MEDICAL CENTER
PeaceHealth St. John Medical Center Cancer Team
The Mammography Clinic at St. John Medical
Center (SJMC) was established in 1986 to provide
a supportive environment where women’s unique
health issues could be addressed. The first clinic
was located off campus with one mammography
machine and two employees. Since then we have
relocated twice, most recently in 1999 to the
SJMC medical office building.
The Breast Center received a substantial donation
from Lee and Connie Kearney and the local
community to renovate and redesign the space to
become the second Kearney Breast Center within
PeaceHealth. The center now has the latest in
technology with two 3-D Hologic systems, the
Affirm breast biopsy unit and GE ultrasound
equipment. Approximately 46 patients are seen
each day for screening and diagnostic exams. There
2
is also an ongoing breast cancer support group that
has been meeting monthly for more than 20 years.
We facilitate a biweekly Breast Case Management
Review, which includes all of the breast cases,
benign and malignant, which have been seen in the
Breast Center. Participating in each conference are
breast surgeons, radiologists, nurses, medical and
radiation oncologists, pathologists, mammography
technologists, and tumor registrars.
Our staff is a close-knit group, and we are well
known within the community for the exceptional
care and customer service we deliver to our
patients. Our technical staff is highly skilled, with
more than 175 years of experience, and most have
been with the clinic since it began. We promote
compassionate patient care in an environment
that supports our patients and our staff.
www.peacehealth.org
Fall 2013
KEARNEY BREAST CENTER
PEACEHEALTH SOUTHWEST MEDICAL CENTER
PeaceHealth Southwest Medical Center Cancer Team
The Kearney Breast Center at PeaceHealth
Southwest Medical Center developed from
small and humble beginnings in a one room
unit located at what was the original St. Joseph
hospital in Vancouver. In 1977, St. Joseph and
Vancouver Memorial hospitals merged forming
Southwest Washington hospital. In 1989, the
name was changed to Southwest Washington
Medical Center (SWMC). In 2004, the unit
was named The Breast Care Center and moved
into its own suite adding an ultrasound room,
bone density and a stereotactic unit. A year
later the breast center traded in its two analog
mammography units and became fully digital.
In 2009, with the help of community donors, the
Kearney Breast Center at SWMC was established
and built. We have brought in state-of-the-art
equipment including three mammography units
that are fully Tomosynthesis (3-D), two ultrasound
units, a stereotactic biopsy unit, bone densitometry
Volume 6, Number 1
and a Breast Specific Gama Imaging (BSGI)
camera in our center, providing women with the
most up-to-date advanced imaging technology.
The Kearney Breast Center has become a
comprehensive Center of Excellence that goes
beyond breast screening and diagnosis, with an
environment that promotes comfort, healing and
support. The center has been designed to give
women an inter-disciplinary approach with our
team of surgical oncologists, medical oncologists,
radiation oncologists, plastic surgeons,
radiologists, technologists, pathologists, social
workers, research coordinators and nurse
navigators. Our staff collectively has 235 years
of experience and on average, sees more than 60
women a day.
We are proud of where we have been and what
we have become in fulfilling our vision of
providing extraordinary care for every patient,
every time, every touch.
Exceptional Medicine
3
“The impressive development of new medical
therapies has increased the number of women
eligible for breast conserving treatment, by
shrinking their tumors before surgery with
appropriately selected regimens.”
— Dane Moseson, MD
4
www.peacehealth.org
Fall 2013
Who will get
Breast Cancer?
E
very woman has an inherent level of risk for developing breast cancer. This
risk is determined in part by her own genetic composition, the age at which
she began menstruating, the age at which she bore her first child, the number
of children she bore, and the age at which she experienced menopause. Use
of oral contraceptives and other female hormone medications, body weight,
smoking history, and alcohol use are also factors. Computer programs are
available to calculate this inherent risk.1 Men develop breast cancer much less
frequently than women, however they are not immune.
According to the current statistics from the
American Cancer Society, breast cancer is the
second most common type of cancer among
women in the United States, following skin
cancer. About 1 in 8 (12%) women in the United
States will develop invasive breast cancer during
their lifetime, while the lifetime risk for men is
1 in 1,000. Breast cancer is the second leading
cause of cancer death in women, second only
to lung cancer. According to the American
Cancer Society’s statistics, 232,340 new cases
of invasive breast cancer and 64,640 new cases
of noninvasive breast cancer will be diagnosed
in 2013, of which 39,620 women will die from
breast cancer. Approximately 2,240 new cases of
Volume 6, Number 1
invasive breast cancer will be diagnosed in men in
the United States and 410 men will die from breast
cancer this year. But the good news is that there
are more than 2.8 million breast cancer survivors
in the United States.
Death rates from breast cancer have been
declining since 1989, with larger decreases in
women younger than age 50. These decreases
are believed to be the result of increased
awareness, earlier detection through screening,
and improved treatment. Early detection is
key, because small breast cancers are much less
likely to have spread beyond the breast to lymph
nodes or other organs when compared to large
Exceptional Medicine
5
cancers. Improvements in surgical techniques,
chemotherapy, hormone and targeted therapies,
and radiation therapy have increased the
numbers of women and men surviving breast
cancer. Research to discover new and better
ways to diagnose and treat breast cancer offers
the promise of even better survival rates in the
future. We are excited to share with you all of
the ways in which the dedicated professionals at
PeaceHealth Kearney Breast Centers care for our
patients with breast cancer.
BREAST CANCER STATISTICS FOR PEACEHEALTH
LOWER COLUMBIA REGION
Table 1: Age at Diagnosis 2003-2012
Female Only Analytic Cases
Table 2: Breast Cancer Clinical Stage at
Diagnosis, 2012
n=3,930
n=339
Age at Diagnosis
Number of Cases
Stage at Diagnosis
Number of Cases
0-29
19
Stage 0
68
30-39
150
Stage1
153
40-49
603
Stage 2
65
50-59
1011
Stage 3
24
60-69
1031
Stage 4
10
70-79
721
Unknown
19
80-89
356
90+
39
Based on AJCC Clinical Stage
Figure 1: Age-specific Incidence of Breast Cancer Measured Between 2003-2012,
PeaceHealth Lower Columbia Region
n=3,930
1200
1011
1031
Number of cases
1000
800
721
603
600
356
400
150
200
39
19
0
0-29
30-39
40-49
50-59
60-69
70-79
80-89
90+
Age at diagnosis
6
www.peacehealth.org
Fall 2013
How is
Breast Cancer Diagnosed?
M
asses or abnormalities in the breast tissue may be identified through
physical examination or with the aid of imaging techniques such
as mammography, ultrasound, or magnetic resonance imagery (MRI).
Abnormalities in the breast can be caused by benign, pre-malignant, or
malignant disease processes.
Most breast cancers in the United States are
detected due to abnormal mammograms,
however, some women present with a
palpable breast mass. Approximately 15% of
women diagnosed with breast cancer have a
palpable breast mass that is not visualized on
mammography and 30% of women present with a
breast mass in between screening mammograms.2
Typically, breast cancer presents as a hard,
fixed, non-tender mass with irregular borders.
Women with locally advanced disease may
present with axillary adenopathy or skin changes
such as erythema, thickening or dimpling of
the skin (known as peau d’orange), which
suggests inflammatory breast cancer. Women
with metastatic breast cancer often have bone,
liver, and lung involvement so they frequently
present with back pain, nausea, abdominal pain,
shortness of breath, and/or cough.
Volume 6, Number 1
IMAGING
Breast cancer develops in breast tissue, which is
why it occurs in all mammals, male and female,
young and old. There are ways of decreasing
occurrence, but, with the exception of removing
all breast tissue, there is no means of prevention.
In this setting, detection is of utmost importance;
the sooner, the better. This is what breast
imaging is all about; detecting all of the cancers
at their earliest stage. At some point, all cancers
can be palpated as a mass. In breast imaging, we
want to find it before that point. Fortunately,
through the efforts of many radiologists and
much research, breast imaging and screening
programs have been a great success story, which
continues to unfold.
Exceptional Medicine
7
Figure 2: Breast tomosynthesis can demonstrate lesions not otherwise seen in
mammography, and provides computer assisted guidance for needle biopsy of those lesions.
2D Digital Mammogram Image vs 3D Digital Mammogram Slice
The screening 2D
mammogram shows a
possible lesion in the
central breast.
Even when the 2D view
is enlarged, the margins
are difficult to assess.
3D mammography
shows a spiculated
mass—very likely a
malignancy.
Breast imaging began with mammography.
In fact, when Wilhelm Roentgen developed
radiology in 1895, he predicted that one of
the greatest impacts of radiology would be on
breast cancer. Since then, screening programs
evaluating variables of imaging frequency, patient
age, number of views, and radiation dose evolved
under much scrutiny and criticism throughout
the world. Although breakthroughs in technology
have greatly improved mammograms, finding
the cancers remains a challenge. As in scientific
research, where you want to assume the negative
of your hypothesis and prove it wrong, the
radiologist must assume every mammogram
has a cancer until proven otherwise. Or, less
grimly, asking “Where’s Waldo?” However,
the breast cancer Waldo can wear various hats
and can be as subtle as crossed lines or can
hide in a dense forest of breast tissue. Digital
mammography provided greater contrast and
resolution over film screen mammography,
and the recent development of digital breast
tomosynthesis, currently used at both of the
PeaceHealth Kearney Breast Centers, allows
radiologists to separate overlying linear densities
and see “between the trees” to more confidently
determine if there is reason for concern.
Tomosynthesis, represented in Figure 2, is similar
to computed tomography (CT), but with a much
lower radiation dose, comparable to screening
mammography. It allows radiologists to find
more cancers at an early stage, more confidently
discern benign breast tissue and therefore avoid
repeat imaging with focal compression.
But, there’s more. Fortunately, mammography is
only one modality under the umbrella of breast
imaging. Each modality is comparable to one
of the five senses we use for detecting things in
Figure 3: Ultrasound guided biopsy with real time imaging confirms that the biopsy needle
aperture is in the abnormal tissue.
8
www.peacehealth.org
Fall 2013
everyday life. Mammography is our x-ray vision,
which may not work in deep dense breast tissue.
Some cancers are mammographically invisible/
occult. So, just as people depend on their sense
of hearing in the dark, the radiologist uses ultrasound when something is suspected but not seen
(Figure 3). This is especially common when a
patient feels a breast lump in the setting of dense
breast tissue or a normal mammogram. Sound
waves also provide additional characterization
of a visible, concerning mammographic
finding. Advances in ultrasound are even more
unbelievable than those in mammography,
allowing characterization of vascularity, tissue
elasticity and vocal fremitus, all without
radiation of the tissue. It also provides
opportunity for the radiologist to feel the lesion,
examine the axilla for enlarged lymph nodes, and
address patient concerns.
Another exciting modality used in both Kearney
Breast Centers is Breast MRI (Figure 4). This
modality is also without radiation, which we
strive to minimize in breast tissue. MRI is
performed on all the breast tissue, chest wall
and axillary tissue, at the same time and without
compression. MRI is the most sensitive and
specific means available for characterizing
Figure 4. Breast MRI is reserved for cases of known
breast cancer, extremely dense breast tissue, and
strong family history of breast cancer, and can also be
used to guide needle biopsy under minimally invasive
techniques.
Volume 6, Number 1
Exceptional Medicine
9
non-osseous, soft tissue structures. However,
it is not necessary, pragmatic, cost effective or
amenable to functioning as a front line modality
in screening programs, and is used for special
high risk, preoperative or postoperative patients.
The usefulness and clinical indications for MRI
continue to expand.
Each of these modalities is not only used
to detect cancers, but to provide guidance
for biopsy and subsequent diagnosis of the
abnormality. Ultrasound guided biopsies
are preferable because of low costs, low
complications, increased comfort and absence
of radiation. Therefore, ultrasound is often
performed to determine the feasibility to
perform US guided biopsy of a mammographic
lesion. However, if suspicious calcifications
or architectural distortion is only seen in
digital mammographic tomosynthesis or MRI,
they must be sampled using the modality by
which they were detected. The Kearney Breast
Centers have prepared for this with equipment
facilitating advanced biopsy techniques using
each modality.
10
In this country, imaging results are processed
into a standardized classification system refined
by the American College of Radiology. Patient
history, risk factors, annual mammographic
findings and recommendations are recorded
in terms of the Breast Imaging Reporting and
Data System, fondly known as BIRADS, which
has become the common “language” of breast
imaging. The nationwide standardization and
consistency of this system provides continuity
of care throughout the country and facilitates
auditing and registries of data to evaluate trends,
enhance research and keep us on the front line.
Consequently, recommendations from the United
States Preventative Services Task Force, several
years ago, regarding screening mammography,
could efficiently and definitively be determined
to result in an estimated 71% increase in breast
cancer morbidity and mortality as compared
to recommendations by the American Cancer
Society guidelines3.
In breast imaging, we don’t want anyone to have
breast cancer, but if they do, we can’t wait to find
it and expedite the best possible outcome.
www.peacehealth.org
Fall 2013
What are the
Types of Breast Cancer?
E
ven though the patient and the pathologist rarely meet, the pathologist is
an important part of the team when it comes to the diagnosis and treatment
of breast cancer. It is the pathologist who confirms the presence or absence of
malignancy, determines whether or not the cancer was removed in its entirety,
and provides essential information about the unique characteristics of a patient’s
cancer. This information helps the medical and radiation oncologist to formulate
a treatment plan that addresses each patient’s individual needs. After tissue
is removed from a patient, the pathologist examines it first without the aid of
magnification, and then with the aid of the microscope.
The structure of the breast is relatively simple.
It is composed of clusters of tiny glands, called
acini, which are arranged in lobules and
connected to a system of ducts, which in turn exit
the breast at the nipple. The acini and ducts are
surrounded by connective tissue and fat, which
support and cushion the breast. The cells of the
ducts and acini are sensitive to the hormonal
fluctuations of the menstrual cycle and pregnancy
over the course of a woman’s lifetime. This
sensitivity allows for the production of milk for
the nourishment of an infant, but can also impart
vulnerability for the development of malignant
cells in the breast.
Volume 6, Number 1
Benign breast changes are very common; some
reports suggest it may affect as many as nine
out of ten women.4 Benign changes, which can
present as mammographic changes or lumps,
include fibrocystic change, fibroadenoma, and
intraductal papilloma, and benign soft tissue
tumors such as lipomas. Atypical (pre-malignant)
breast changes are not malignant, but they do
carry with them an increased risk for malignancy.
This risk is roughly four times the patient’s
baseline risk.5 These atypical changes include
atypical ductal hyperplasia (DIN1) and atypical
lobular hyperplasia (LIN1). They have some,
Exceptional Medicine
11
but not all, of the features of carcinoma in-situ
and can be seen at the outer edge of a cancer.
The actual incidence of atypical hyperplasia
is difficult to quantify; however in one recent
study, atypical ductal hyperplasia (DIN1) was
identified in 2-11% of core biopsies done because
of abnormalities identified on breast imaging.6
Carcinoma in-situ occurs as two specific types.
Ductal carcinoma in-situ (DIN2 and DIN3)
is thought to begin in the ducts of the breast.
Lobular carcinoma in-situ (LIN2 and LIN3) is
thought to originate in the lobules of the breast.
In either type, cells with malignant features fill
the ducts and/or acini of the breast, but they do
not extend out into the supporting connective
tissue or fat. Ductal carcinoma in-situ and
intraductal carcinoma are synonymous.
Invasive breast carcinomas also are divided
into ductal and lobular types. Malignant cells,
with features resembling the cells lining the
ducts or the cells of the lobules, spread out
of the ducts and/or acini into the connective
tissue and fat of the breast. Some terms that are
used in pathology reports to describe invasive
carcinoma of the breast include invasive ductal
(or lobular) carcinoma, or infiltrating ductal
(or lobular) carcinoma. Certain special types
of invasive or infiltrating carcinoma include
pure tubular carcinoma, classic invasive lobular
carcinoma, mucinous carcinoma, medullary
carcinoma, adenoid cystic carcinoma, and
metaplastic carcinoma. These special types each
carry with them certain characteristic patterns of
architecture and behavior in terms of growth
rate and likelihood of metastasis.
Table 3: Primary Tumor
Primary Tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
Tis(DCIS)
Ductal carcinoma in situ
Tis(LCIS)
Lobular carcinoma in situ
Tis(Paget’s)
12
Paget’s disease of the nipple NOT associated with invasive carcinoma and/or carcinoma
in situ (DCIS and/or LCIS) in the underlying breast parenchyma. Carcinomas in the breast
parenchyma associated with Paget’s disease are categorized based on the size and
characteristics of the parenchymal disease, although the presence of Paget’s disease
should still be noted
T1
Tumor < 20 mm in greatest dimension
T1mi
Tumor < 1 mm in greatest dimension
T1a
Tumor > 1 mm but < 5 mm in greatest dimension
T1b
Tumor > 5 mm but < 10 mm in greatest dimension
T1c
Tumor > 10 mm but < 20 mm in greatest dimension
T2
Tumor > 20 mm but < 50 mm in greatest dimension
T3
Tumor > 50 mm in greatest dimension
T4
Tumor of any size with direct extension to the chest wall and/or the skin (ulceration or skin
nodules). Note: Invasion of the dermis alone does not qualify as T4
T4a
Extension to the chest wall, not including only pectoralis muscle adherence/invasion
T4b
Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d’orange) of
the skin, which do not meet criteria for inflammatory carcinoma
T4c
Both T4a and T4b
T4d
Inflammatory carcinoma (see “Rules for Classification”)
www.peacehealth.org
Fall 2013
Both in-situ and invasive/infiltrating carcinoma
are graded by the pathologist to convey to the
surgeon and oncologist just how aggressive the
cancer is likely to be. Ductal carcinoma in-situ
is graded as low, intermediate and high grade.
The Van Nuys system is the most commonly
used system for the grading of in-situ breast
carcinoma. Invasive/infiltrating carcinomas
are graded as well differentiated (grade 1),
moderately differentiated (grade 2) and poorly
differentiated (grade 3). The Elston-Ellis
modification of the Scarff-Bloom-Richardson
system (also known as the Nottingham system)
is used for grading invasive/infiltrating breast
carcinoma. This system uses the rate at which
the tumor forms glands, the appearance of the
tumor cell nuclei, and the rate of tumor cell
division to assign the tumor grade. Generally
speaking, well differentiated carcinomas tend to
be the least aggressive and poorly differentiated
carcinomas tend to be the most aggressive.
The pathologist also tests the patient’s cancer for
estrogen and progesterone hormone receptor
status, proliferation index, and HER-2/neu status.
Recently, proprietary tests have been developed
which are useful and appropriate for defined
groups of breast cancer patients. These tests may
be indicated for patients with small, low grade,
invasive tumors that have not metastasized to
regional lymph nodes. The tests predict the
probability of future recurrence or metastasis of
the cancer outside of the breast, and can help the
oncologist determine whether or not the patient
is likely to benefit from chemotherapy. They
are not intended for use in patients with large,
high grade tumors or tumors with lymph node
metastasis, as these patients are known to be at
high risk for recurrence and generally do need
chemotherapy.
Based on all of the information obtained from
the surgical specimen, the pathologist assigns
a pathologic stage to the patient’s cancer, based
Table 4: Regional Lymph Nodes
Regional Lymph Nodes (N)
Clinical
NX
Regional lymph nodes cannot be assessed (e.g. previously removed)
N0
No regional lymph node metastasis
N1
Metastasis to movable ipsilateral level I or level II axillary lymph node(s)
N2
Metastasis to ipsilateral level I or level II axillary lymph nodes that are clinically fixed or
matted; or in clinically detected ipsilteral internal mammary nodes in the absence of
clinically evident axillary lymph node metastasis
N2a
Metastasis to ipsilateral level I or level II axillary lymph nodes fixed to one another
(matted) or to other structures
N2b
Metastasis only in clinically detected ipsilateral internal mammary lymph nodes and in
the absence of clinically evident axillary lymph node metastasis
N3
Metastasis to ipsilateral infraclavicular (level III axillary) lymph node(s) with or without
level I or level II axillary lymph node involvement: or in clinically detected ipsilateral
internal mammary lymph node(s) with clinically evident level I or level II axillary lymph
node metastasis; or metastasis in ipsilateral supracalvicular lymph node(s) with or
without axillary or internal mammary lymph node involvement
N3a
Metastasis to ipsilateral infraclavicular lymph node(s)
N3b
Metastasis to ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
N3c
Metastasis to ipsilateral supraclavicular lymph node(s)
Volume 6, Number 1
Exceptional Medicine
13
on the American Joint Committee on Cancer
TNM Staging System.7 This pathologic stage is
identified as the “pTNM” stage on the pathology
report. It is determined based on the presence or
absence of invasive/infiltrating carcinoma, the
size of the tumor as measured in the pathology
specimen, presence or absence of lymph node
metastasis and number of lymph nodes involved,
and presence or absence of metastatic carcinoma
beyond the breast and its adjacent lymph nodes.
for breast cancer is an internationally accepted
system used to determine the disease stage.
Staging is used to guide treatment decisions
regarding appropriate local and systemic
therapies. In addition, staging provides us with
important prognostic information.
All patients with breast cancer need to be
assigned a clinical and pathologic stage. The
tumor node metastasis (TNM) staging system
Finally, based on a combination of the clinical,
imaging and pathology results, a final stage
known as the Collaborative Stage, is assigned.8
This staging is used to guide treatment decisions
regarding appropriate local and systemic
therapies. In addition, staging provides us with
important prognostic information.
Table 5: Anatomic Stage/
Prognostic Groups
Figure 5: Breast Cancer –
Clinical Stage at Diagnosis
Stage 0
Tis
N0
M0
Stage IA
T1*
N0
M0
T0
N1mi
M0
T1*
N1mi
M0
T0
N1**
M0
T1*
N1**
M0
T2
N0
M0
T2
N1
M0
T3
N0
M0
T0
N2
M0
T1*
N2
M0
T2
N2
M0
T3
N1
M0
T3
N2
M0
T4
N0
M0
T4
N1
M0
T4
N2
M0
Stage IIIC
Any T
N3
M0
Stage IV
Any T
Any N
M1
Stage IB
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Notes:
14
3%
7%
6%
Stage 0
20%
Stage 1
Stage 2
19%
Stage 3
45%
Stage 4
Unknown
Diagnosis Year 2012 PeaceHealth Lower Columbia Region
*T1 includes T1mi.
**T0 and T1 tumors with nodal micrometastases only
are excluded from Stage IIA and are classified
Stage IB.
www.peacehealth.org
Fall 2013
Table 6: Pathologic
Pathologic (pN)†**
pNX
Regional lymph nodes cannot be assessed (eg, previously removed, or not removed for
pathologic study)
pN0
No regional lymph node metastasis identified histologically
pN0(i-)
No regional lymph node metastases histologically, negative immunohistochemistry (IHC)
pN0(i+)
Malignant cells in regional lymph node(s) no greater than 0.2 mm (detected by H&E or IHC
including isolated tumor cell clusters (ITC))
pN0(mol-)
No regional lymph node metastases histologically, negative molecular findings (RT-PCR)
pN0(mol+)
Positive molecular findings (RT-PCR), but no regional lymph node metastases detected by
histology or IHC
pN1
Micrometastases; or metastases in 1-3 axillary lymph nodes; and/or in internal mammary nodes
with metastases detected by sentinel lymph node biopsy but not clinically detected
pN1mi
Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm)
pN1a
Metastases in 1-3 axillary lymph nodes, at least one metastasis greater than 2.0 mm
pN1b
Metastases in internal mammary nodes with micrometastases or macrometastases detected
by sentinel lymph node biopsy but not clinically detected
pN1c
Metastases in 1-3 axillary lymph nodes and in internal mammary lymph nodes with
micrometastases or macrometastases detected by sentinel lymph node biopsy but not
clinically detected
pN2
Metastases in 4-9 axillary lymph nodes; or in clinically detected internal mammary lymph
nodes in the absence of axillary lymph node metastases
pN2a
Metastases in 4-9 axillary lymph nodes (at least one tumor deposit greater than 2.0 mm)
pN2b
Metastases in clinically detected internal mammary lymph nodes in the absence of axillary
lymph node metastases
pN3
Metastases in ten or more axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes;
or in clinically detected ipsilateral internal mammary lymph nodes in the presence of one or more
positive level I, II axillary lymph nodes; or in more than three axillary lymph nodes and in internal
mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph
node biopsy but not clinically detected; or in ipsilateral supraclavicular lymph nodes
pN3a
Metastases in ten or more axillary lymph nodes (at least one tumor deposit greater than
2.0 mm); or metastases to the infraclavicular (level III axillary lymph) nodes
pN3b
Metastases in clinically detected ipsilateral internal mammary lymph nodes in the presence
of one or more positive axillary lymph nodes; or in more than three axillary lymph nodes and
in internal mammary lymph nodes with micrometastases or macrometastases detected by
sentinel lymph node biopsy but not clinically detected
pN3c
Metastases in ipsilateral supraclavicular lymph nodes
Table 7: Distant Metastasis
Distant Metastasis (M)
M0
No clinical or radiographic evidence of distant metastasis
cM0(i+)
No clinical or radiographic evidence of distant metastasis, but deposits of molecularly or
microscopically detected tumor cells in circulation blood, bone marrow, or other non-regional
nodal tissue that are no larger than 0.2 mm in a patient without signs or symptoms
of metastasis
M1
Distant detectable metastasis as determined by classic clinical and radiographic means and/or
histologically proved larger than 0.2 mm
Volume 6, Number 1
Exceptional Medicine
15
CANCER REGISTRY: A WEALTH OF INFORMATION
PeaceHealth Cancer Registrars
T
he data you have before you is the combined work of our dedicated
cancer registrars. These individuals have specialized training in
documenting exactly how cancer patients are treated, and then closely
tracking outcomes. This data is surveyed by the Chicago-based Commission
on Cancer every three years to evaluate accuracy.
As a liaison physician of the commission, serving
various roles for 30 years, Dr. Moseson has had
the opportunity to observe this survey process
at a national level in a variety of institutions
as a member of the Approvals Committee. By
comparison with national norms, our registrars
in Southwest Washington are consistently
excellent, routinely achieving commendations
from the survey teams. As we move forward into
accountable care, this capability is invaluable
to our communities seeking assurance that
state-of-the-art, meeting or exceeding national
benchmarks, is being delivered.
16
This year’s report focuses on breast cancer,
extracting information from over 40,000
patients tracked by this registry system. For
those interested, the registry has much more
detailed information utilized by physicians
evaluating specific areas of progress. Attempting
to define quality in real time, we are moving
into a system of Rapid Quality Reporting known
as RQRS. Nationally, it has been determined
that there are key steps in successful treatment
for specific cancers. Instead of limiting the
registry to retrospective information about
survival and recurrence rates, we are developing
www.peacehealth.org
Fall 2013
the capability to monitor ongoing treatment
protocols to ensure that each patient is
completing each phase of therapy. For example,
it is known that to be effective at curing breast
cancer by lumpectomy, appropriate coordination
with radiation and systemic therapy is critical.
The RQRS program is a way of tracking that
there is follow through with the complete
treatment plan. Our registry system is invaluable
as we collaborate to provide effective, efficient
care in this new era of healthcare reform.
Table 8: Comparative Cancer Incidence LCR vs WA State vs National
Comparative Cancer Incidence
Lower Columbia Region (LCR) vs Washington State vs National
LCR
Site
WA State
Number
Percent
Number
National
Percent
Number
Percent
Breast
272
18
5,240
15
226,870
14
Lung &
Bronchus
222
14
4,700
13
226,160
14
Colon &
Rectum
119
8
2,770
8
143,460
9
Melanoma
63
4
2,140
6
76,520
5
Corpus Uteri
85
6
1,080
3
47,130
3
Leukemia
27
2
1,050
3
47,150
3
Cervix
20
1
220
1
12,170
1
Prostate
96
6
5,060
14
241,740
15
Bladder
65
4
1,670
5
73,510
4
NH
Lymphoma
85
5
1,600
4
70,130
4
493
32
10,260
28
474,070
28
1,528
100
35,790
100
1,638,910
100
Other
Total
*Washington State and National Data from ACS Cancer Facts and Figures 2012
*Totals exclude in situ carcinomas except for urinary bladder
Volume 6, Number 1
Exceptional Medicine
17
How is
Breast Cancer Treated?
T
here are two related issues of importance to breast cancer patients and
their families. The first is survival and the second is the impact of surgery,
radiation, and chemotherapy on their lives. Figure 6 depicts survival of 1,941
breast cancer patients, broken down into those treated by breast conserving
methods (lumpectomy) or by mastectomy.
Treatment decisions are made based on a
combination of factors about the tumor, which
is then grouped into five stages beginning with
Stage 0, which means there has been no spread of
the cancer beyond the confines of the breast duct,
through to those tumors that have already spread to
other organs, Stage 4. Although hotly contested in
the past, one can see that breast conserving surgery
in appropriately selected patients has been very
effective. The availability of excellent screening
capabilities in our area have resulted in a big shift
over time to early stage 0/1 cancers where you can
see the 5-year survival of both types of treatment
to be over 95%. The impressive development of
new medical therapies has increased the number
18
of women eligible for breast conserving treatment,
by shrinking their tumors before surgery with
appropriately selected regimens.
Figure 7 compares patient outcomes from
our Lower Columbia Region with national
benchmarks from the National Cancer Data Base.
This data combines patients treated with both
breast conserving surgery and mastectomy.
It is again reassuring to see that multidisciplinary
teams of specialists working together in our
communities on the north shore of the Columbia
River have been able to match outcomes from
the more than 400,000 patients treated during a
similar time frame nationally.
www.peacehealth.org
Fall 2013
Although these results are very reassuring, a report
presented at the San Antonio Breast Conference in
2012 prompted us to look back even further to see
if we had experienced the same findings as those
researchers looking at really long term survival for
breast cancer patients. The results of the ATLAS
trial suggested that perhaps our long-term survival
rates could be improved by continuing to utilize
hormonal modulating therapies for ten years
instead of the traditional five years commonly
accepted to be appropriate.
lack of exercise have a very deleterious effect on
breast as well as other cancer related issues. The
multidisciplinary breast care teams at the Kearney
Breast Centers are in the process of implementing
survivorship plans that will include specific
recommendations for patients.
Now that the issue as to whether or not breast
conserving surgery is as safe as mastectomy has
been resolved; there are multiple approaches
being considered to decrease other aspects of
harm associated with breast cancer treatment.
Our pathologists are finding better ways to define
each cancer by using various markers. This,
in turn, allows our oncologists to personalize
treatment plans. Our radiation oncologists are
looking at treating only the portions of the breast
containing cancer, and over shorter time frames.
Our medical oncologists are now shrinking
cancers in advance of surgery, to allow more
women to preserve their own breast if they wish
to do so. The excellent medical oncology team
at PeaceHealth is also examining situations in
which chemotherapy regimens are modified to
Figure 8 compares the 10-year survival of patients
that we have treated to national averages. As
you can see in this graph, there is a small, but
continued, loss of survival in each stage which
supports the ATLAS trial report. This report
suggests we can achieve better long term results
by continuing hormonal treatment for 10 years, in
addition to other interventions. There is increasing
data that supports lifestyle choices, which include
modifying exercise and diet that will have a
very significant impact on long term health and
survival. It has become apparent that obesity and
Figure 6: Mastectomy Compared with Breast Conserving Therapy
Lower Columbia Region n=1,941 total cases.
Observed 5-year Survival by Treatment for Breast Cancers diagnosed 2003-2007
100
80
60
40
20
0
Stage 0
Mastectomy
1 year
100%
Stage 0
BCS
100%
Stage 1
Mastectomy
99%
Stage 1
BCS
99%
Stage 2
Mastectomy
95%
Stage 2
BCS
99%
Stage 3
Mastectomy
96%
Stage 3
BCS
100%
Stage 4
Mastectomy
100%
Stage 4
BCS
87%
Overall
Survival
Mastectomy
97%
Overall
Survival
BCS
99%
2 years
100%
97%
99%
98%
92%
98%
87%
95%
63%
75%
92%
97%
3 years
100%
95%
95%
97%
89%
96%
81%
86%
55%
65%
88%
95%
4 years
95%
92%
92%
95%
83%
95%
73%
84%
55%
55%
81%
94%
5 years
95%
92%
87%
94%
81%
92%
71%
77%
47%
42%
80%
91%
Volume 6, Number 1
Exceptional Medicine
19
Figure 7: Observed 5-year Survival for Breast Cancer Cases Diagnosed 2003-2005,
Lower Columbia Region
n=1,124 compared with the National Cancer Data Base n = 405,697
100
80
60
40
20
0
1 year
LCR
Stage 0
2 years
NCDB
99%
LCR
99%
3 years
NCDB
98%
LCR
99%
4 years
NCDB
97%
LCR
98%
5 years
NCDB
94%
LCR
97%
NCDB
93%
96%
Stage 1
99%
99%
98%
98%
95%
96%
93%
94%
92%
92%
Stage 2
97%
98%
95%
95%
92%
92%
90%
88%
86%
85%
Stage 3
94%
94%
83%
85%
76%
78%
64%
71%
62%
66%
Stage 4
77%
65%
62%
47%
40%
35%
36%
27%
25%
21%
Overall
97%
97%
95%
94%
91%
91%
88%
88%
86%
85%
Figure 8: Observed 10-year Survival for Breast Cancer Cases Diagnosed 1998-2002,
Lower Columbia Region compared with the National Cancer Database
NCDB n=680,855. Survival Comarison with NCDB only available for the first 5 years.
100
80
60
40
20
0
1 year
LCR
LCR
NCDB
3 years
LCR
NCDB
4 years
LCR
NCDB
5 years
LCR
LCR
LCR
LCR
LCR
LCR
100%
99%
99%
99%
97%
98%
95%
97%
95%
95%
89%
89%
88%
85%
84%
Stage 1
99%
99%
97%
97%
97%
95%
93%
93%
91%
91%
87%
83%
80%
77%
75%
Stage 2
97%
98%
95%
94%
90%
90%
86%
86%
82%
82%
77%
74%
72%
68%
65%
Stage 3
93%
92%
83%
80%
69%
70%
62%
63%
58%
57%
48%
43%
40%
37%
37%
Stage 4
44%
62%
19%
44%
18%
32%
18%
24%
14%
19%
7%
7%
2%
2%
2%
Overall
97%
97%
94%
93%
91%
90%
88%
87%
85%
84%
80%
77%
74%
71%
69%
www.peacehealth.org
NCDB
6
7
8
9
10
years years years years years
Stage 0
20
NCDB
2 years
Fall 2013
include a more select group of patients. Surgeons
are examining ways to decrease the morbidity
of surgery in the lymph nodes. Phenomenal
advances in reconstructive surgery, imaging and
the biologic understanding of breast cancer are
allowing those women requiring mastectomy
to be reconstructed in a fashion that it is very
difficult to discern they have even had surgery.
These developments are guided by national
clinical trials that prove what can be done. The
results of the clinical trials are then evaluated by
multidisciplinary teams to determine what can be
done effectively in our own community. Again, the
work of our excellent registry staff is tremendously
important to document that treatment delivered
in our community meets or exceeds national
benchmarks, as measured by short and long term
patient survival. A team of physicians review and
debate the merits of the individualized treatment
plans offered to each patient at the Kearney
Breast Centers. Those of us who provide care to
the patients of the Lower Columbia Region are
extremely grateful for the generous donations
made by the Kearney family and multiple other
donors in our community. Their gifts allow us to
deliver comprehensive state of the art care in a
setting that encourages teamwork and professional
excellence. We are appreciative of the opportunity
presented, and are committed to do our best.
SURGERY
When “less is more...”
As surgeons trained with an emphasis in
oncology, it has been absolutely invigorating
to participate in the evolving treatment of
breast cancer. The report before you includes
data from thousands of cancer patients treated
here in Southwest Washington, compared with
national data. It is especially energizing now
that the generous communities along the north
bank of the Columbia River have come together
to provide support for the complex integrated
networking of the entire breast team now so
crucial in diagnosing and treating breast cancer.
Volume 6, Number 1
Due to philanthropic support, increasingly
important expensive technology is now available.
The Kearney Breast Centers provide a setting for
all specialty physicians to work together in an
environment created to meet the needs of women
in our community. No longer will surgeons
be isolated from their colleagues in imaging,
pathology, medical oncology, research and
radiation therapy. Patient care is becoming more
complex, requiring integrated, multidisciplinary
treatment plans for optimum results.
Surgeons, initially skeptical about departing from
radical surgery, championed the development of
a registry of cancer patients now known as the
National Cancer Data Bank (NCDB). Amazingly
it was also a surgeon, Dr. Bernard Fischer, who
took the lead in identifying that “less surgery may
actually be more beneficial” through multiple
clinical trials begun in the National Surgical
Adjuvant Breast Project. This NCDB registry
system, supported by PeaceHealth, has allowed
us to track the effectiveness of the increasingly
innovative ways we now treat breast cancer as we
enter this period of accountable care.
In Southwest Washington, we have more than 25
years of data which supports the fact that radical
mastectomy has no higher cure rate than lesser
procedures. Initially, only small cancers could be
treated by breast preservation techniques. Over
the past decade, we have developed the ability
to better understand an individual patient’s
tumor biology. This has led to the development
of treatments that shrink the patient’s tumor and
allow smaller operations to be equally effective
as more radical procedures. This technique,
known as neoadjuvant therapy, may utilize either
chemotherapy or hormonal treatment, followed
by surgery and radiation therapy. Each step
in the process must be coordinated, requiring
increasingly complex teamwork between
specialty physicians. The tumor registry system
has been integral in validating safe incorporation
of these techniques into community practice.
Exceptional Medicine
21
With acceptance that less disfiguring operations can
be effective when applied to the breast itself, there
has been an equally effective move to decrease the
extent of surgery in the axilla (arm pit) which is
the cause of arm swelling and discomfort in many
patients. At the end of this report, you will find a
brief summary of exciting current clinical trials
validating the changes taking place in breast care.
”And conversely,
when more is better...”
In concert with the growing understanding of
tumor biology, there is also growing insight as
to genetics and host factors that predict high
risk for the development of breast cancer. The
innovation in reconstructive surgery is absolutely
astounding, at least to those of us familiar with
the initial attempts at breast reconstruction. With
proper patient selection, preventive procedures
such as bilateral mastectomy with immediate
reconstruction allow selected women to maintain
their physical appearance to a point it is frequently
hard to tell that the woman has had surgery at all.
In selected patients, the nipple areolar complex
may even be preserved. The surgery is complicated,
requiring specialized techniques, but is very
rewarding for those patients who elect this option.
As surgeons trained in oncology, it is intriguing that
it is now the plastic and reconstructive surgeons
that are doing these larger complex operations, and
doing them extremely well.
SYSTEMIC THERAPY
Systemic therapy is usually given in the adjuvant
setting in patients with stage I-III disease to
decrease the risk of recurrence and cancer-related
deaths. It is becoming more common, though, for
systemic therapy to be given in the neoadjuvant
setting to help shrink large tumors before surgery to
increase the likelihood of being able to do breastconserving surgery. In patients with stage IV breast
cancer, systemic therapy is utilized to control tumor
growth, improve cancer-related symptoms and
prolong survival. Oncologists use three types of
systemic therapy to treat breast cancer: hormone
therapy, targeted therapy and chemotherapy.
22
Hormone therapy
About 75% of breast cancers express the estrogen
and progesterone receptors. These cancers are
fueled by estrogen so hormonal therapies that
decrease estrogen levels or block the estrogen
receptor are very effective in decreasing relapse
rates. Tamoxifen is a selective estrogen receptor
modulator (SERM) which binds to the estrogen
receptor and has anti-estrogen effects on
breast tissue and pro-estrogen effects on the
bones, uterus, liver and coagulation system. It
can be used in both pre-menopausal and postmenopausal women. Tamoxifen decreases the risk
of recurrence by 41% and risk of death by 33%.9
Recent evidence suggests that ten years of
tamoxifen is superior to five years with a 3-4%
decreased risk of recurrence and 2% decreased risk
of death with a longer course of treatment.10, 11
Aromatase inhibitors, such as anastrazole, letrozole
and exemestane, block the aromatase enzyme
that converts androgen into estrogen. Aromatase
inhibitors only work in post-menopausal women
and are recommended for five years in the adjuvant
setting. Aromatase inhibitors are preferred in postmenopausal women since they are associated with
a 3% decreased risk of recurrence when compared
to tamoxifen.12 In addition, aromatase inhibitors
have a safer side effect profile. Tamoxifen increases
a woman’s risk of uterine cancer and blood
clots. Aromatase inhibitors are associated with
osteoporosis and musculoskeletal complaints.
Targeted Therapy
HER-2/neu is a trans-membrane tyrosine kinase
receptor and a member of the epidermal growth
factor receptor (EGFR) family. Activation of
this class of cellular receptors leads to increased
activity of a variety of molecular pathways
associated with tumor growth. Approximately
20% of breast cancers overexpress the HER-2/
neu receptor. Trastuzumab (Herceptin) is a
monoclonal antibody that binds to the HER-2/
neu receptor. Prior to the advent of trastuzumab,
HER-2/neu positive breast cancers were more
aggressive with a higher rate of relapse and worse
www.peacehealth.org
Fall 2013
Table 9: Breast Cancer First Course Treatment by AJCC Stage, Lower Columbia Region 2012*
Stg 0
Stg I
Stg II
Stg III
Stg IV
Unknown
Total
D
0
2
2
2
2
0
8
D, C
0
0
1
0
0
0
1
D, H
0
1
1
1
0
0
3
D, O
1
0
0
0
0
0
1
D, S
19
16
9
0
1
1
46
D, S, C
0
3
13
8
3
0
27
D, S, C, H
0
3
6
3
1
0
13
D, S, H
5
26
12
0
1
0
44
D, S, R
9
12
3
0
0
0
24
D, S, R, C
0
1
8
6
1
0
16
D, S, R, C, H
0
2
13
12
0
0
27
D, S, R, H
11
52
14
2
1
0
80
S
10
8
0
0
0
0
18
S, C
0
2
0
0
1
0
3
S, R
3
0
0
0
0
0
3
S, R, C
0
1
0
0
0
0
1
S, R, C, H
0
0
0
2
0
0
2
S, R, H
6
5
2
0
0
0
13
S, R, H, O
0
0
0
1
0
0
1
Hospice care only
0
0
0
1
0
0
1
69
137
85
38
11
1
341
Total
D = Diagnostic procedure
D,C = Diagnostic procedure, Chemotherapy
D,H = Diagnostic procedure, Hormone Therapy
D,O = Diagnostic procedure, Other Treatment
D,S = Diagnostic procedure, Surgery
D,S,C = Diagnostic procedure, Surgery, Chemotherapy
D,S,C,H = Diagnostic procedure, Surgery, Chemotherapy,
Hormone Therapy
D,S,H = Diagnostic procedure, Surgery, Hormone Therapy
D,S,R = Diagnostic procedure, Surgery, Radiation
D,S,R,C = Diagnostic procedure, Surgery, Radiation and
Chemotherapy
D,S,R,C,H = Diagnostic procedure, Surgery, Radiation,
Chemotherapy and Hormone Therapy
D,S,R,H = Diagnostic procedure, Surgery, Radiation and
Hormone Therapy
S = Surgery
S,C = Surgery, Chemotherapy
S,R = Surgery, Radiation
S,R,C, = Surgery, Radiation, Chemotherapy
S,R,C,H = Surgery, Radiation, Chemotherapy and Hormone
Therapy
S,R,H = Surgery, Radiation and Hormone Therapy
S,R,H,O = Surgery, Radiation, Hormone Therapy and Other
*This table shows combined totals for PeaceHealth Southwest Medical Center and PeaceHealth St. John Medical Center
Volume 6, Number 1
Exceptional Medicine
23
prognosis. Trastuzumab is used in combination
with chemotherapy and continued afterwards
for a total of one year in HER-2/neu positive
breast cancers. Trastuzumab decreases the risk of
recurrence by 40% and the risk of death by 33%.13
There are other HER-2/neu targeted therapies
such as lapatinib, pertuzumab and trastuzumabemtansine that have been recently approved for
use in the metastatic setting and are currently
being studied for use in the adjuvant setting.
Chemotherapy
It can be challenging to determine which
patients will benefit from chemotherapy.
Oncologists must take into account multiple
factors including a patient’s age, co-morbidities,
tumor hormone and HER-2/neu receptor status,
tumor size, tumor grade, and lymph node
status. There are online algorithms such as
AdjuvantOnline that can aid in decision making
by calculating the benefit of chemotherapy based
on certain patient characteristics. In addition,
genomic profiling can provide additional insight
into the biological behavior of a patient’s breast
cancer. Oncotype DX is a validated assay that
examines twenty-one genes and calculates a
recurrence score. Patients with high recurrence
scores derive benefit from chemotherapy
while those with a low recurrence score do
not benefit from chemotherapy. The benefit of
chemotherapy in patients with intermediate
recurrence scores is unknown and currently
being investigated with the clinical study,
TAILORx.
There are multiple chemotherapy drugs that can
be used in various combinations to treat breast
cancer. Anthracyclines, taxanes and alkylating
agents are among the most effective and
commonly used chemotherapy drugs. Frequently
used regimens include dose dense Adriamycin
and cyclophosphamide followed by paclitaxel
(ddAC-T) and docetaxel with cyclophosphamide
(TC). Chemotherapy is often given for
three to five months. Chemotherapy can be
administered before surgery to facilitate breast24
conserving surgery or after surgery to eradicate
micrometastases and decrease the risk of relapse
and cancer-related death.
Patients with metastatic disease are usually
treated with single agents in order to decrease
toxicity unless there is significant organ
involvement which requires a more aggressive
approach. In addition to anthracyclines and
taxanes, anti-metabolites (such as capecitabine
and gemcitabine) and microtubule inhibitors
(such as vinorelbine and eribulin) are preferred
drugs in this setting.
RADIATION
Radiation treatments play an important role in the
multidisciplinary management of most patients
with breast cancer. Data from prospective phase III
trials indicate that for patients treated with breastconserving surgery, radiation reduces the risk of
local recurrence, provides a clinically significant
reduction in distant metastases, and improves
overall survival.14, 15 Radiation treatments are also
well tolerated and, when delivered using modern
technologies, carry a low risk of serious morbidity.
For women who have breast-conserving surgery
radiation therapy treatment options include
standard whole breast radiation (~ six weeks),
hypofractionation (~three weeks), accelerated
partial breast irradiation (one week), and possible
omission of radiation in a select population. The
eligibility, benefits, technologic advances, and
possible disadvantages of these options are as
follows.
Whole breast irradiation (WBI) is considered
standard of care for women who have had
breast-conserving surgery. WBI has the longest
track record and an abundance of literature to
support its efficacy.15, 16 WBI after lumpectomy
has been shown to decrease breast tumor
recurrence by roughly two-thirds when compared
to lumpectomy alone.17 Furthermore, a metaanalysis of 42,000 women noted a statistically
significant survival benefit of 5%.18
www.peacehealth.org
Fall 2013
Improvements in the treatment of whole breast
irradiation include the implementation of 3-D
conformal radiotherapy that uses multiple
radiation fields to deliver precise doses of radiation
to the breast while sparing normal tissue. More
recently, PeaceHealth has implemented the
use of intensity-modulated radiation therapy
(IMRT), which further modifies the radiation
beam, varying the intensity of radiation to allow
for greater sparing, such as decreased acute
skin toxicity.19 The latest developments in the
treatment of breast cancer take into account
respiratory motion, allowing further reduction in
the dose to the heart and lung.20 We expect to have
this ability soon with the purchase of a new CT
simulator that has this capability.
Hypofractionated radiotherapy delivers radiation
in larger doses using fewer treatments. In patients
with early-stage breast cancer treated with
breast-conserving surgery, randomized trials
have found little difference in local control and
survival outcomes between patients treated with
conventionally fractionated whole breast irradiation
and those receiving hypofractionated WBI.21, 22
Eligibility criteria has been addressed by the
American Society of Radiation Oncology (ASTRO)
which includes women over the age of 50, early
stage breast cancer (Stage pT1-2 pN0), women not
receiving chemotherapy, and the ability to deliver
a dose of radiation to the whole breast that does
not exceed a hot or cold spot in excess of 7%.23
The possible disadvantage to hypofractionated
radiotherapy would include a higher risk of late side
effects such as fibrosis. Therefore, it is paramount
to ensure a plan that minimizes the dose to normal
structures such as the heart.
The use of accelerated partial breast irradiation
(APBI) has increased significantly over the last
10 years from 3.4 % in 2003 and increasing to
12.4 % in 2010 for patients receiving radiation
after lumpectomy.24 Accelerated partial-breast
irradiation (APBI) is a technique that typically
delivers a relatively high dose of radiation twice
daily to the breast tissue immediately adjacent
to the lumpectomy cavity region over five
days (Figures 9 and 10). Compelling evidence
supporting the targeting of a smaller volume
of breast tissue with radiation comes from
prospective, randomized studies of lumpectomy
only versus lumpectomy plus WBI. These trials
document that the in-breast cancer recurrence is
most prevalent in the breast tissue immediately
adjacent to the lumpectomy cavity; therefore, the
primary benefit of WBI may be to prevent breast
cancer recurrence at the site of the lumpectomy
bed.15, 24 The benefits of this approach are that it
may facilitate patient compliance with radiation
therapy, increase the attractiveness of breast
conservation, and potentially decrease toxicity,
while also providing greater savings to the health
care system.
There is a growing body of evidence supporting
the benefits of APBI. The largest randomized
study comparing APBI and WBI (NSABP B-39)
has closed with over 4,000 women enrolled
in the study. Although the results of the study
will require a few years to mature before
publication, there have been no significant
adverse events identified by the Data Safety
Monitoring Committee during interim analyses
of these patients. There have been multiple
studies reporting promising results, including
Figure 9: Examples of Radiation Dose
Examples show how the radiation dose (the
colored lines, with the white lines representing
50% of the dose) is targeted to the area where
the original tumor was using three different
partial breast radiation techniques (SAVI, Contura,
interstitial catheters).
Volume 6, Number 1
Exceptional Medicine
25
Figure 10: Whole Breast Radiation
This is in contrast to these examples of standard
whole breast radiation where the entire breast is
considered the target.
a recent update of the Hungarian study which
randomized patients to either APBI versus
WBI.25 After a median follow up of 10.2 years,
the ten-year actuarial rate of local recurrence
was 5.9% and 5.1% in APBI and WBI arms,
respectively (p=0.77). There was no significant
difference in the ten-year probability of overall
survival (80% vs 82%), cause specific survival
(94% vs 92%), and disease free survival (85% vs
84%), either. The rate of excellent-good cosmetic
result was 81% in the APBI, and 63% in the
control group (p<0.01). There was also a recent
publication of the final analysis of the American
Society of Breast Surgeons MammoSite® Breast
Brachytherapy Registry Trial which published
the results of 1,449 cases of APBI with a median
follow-up of 63 months.26 Five-year actuarial
rate of breast tumor recurrence was 3.8%, which
compares favorably to historical rates for whole
breast irradiation. Furthermore, the study noted
that the majority of patients had good to excellent
cosmetic results and few side effects when
compared to traditional radiation.
The American Society of Radiation Oncology
(ASTRO), American Society of Breast Surgeons
(ASBS), and the American Brachytherapy
Society (ABS), have all published guidelines on
appropriate patient selection for treatment with
APBI.27-30 These recommendations were based
on the results of a systematic literature review of
the APBI data and were supplemented by expert
opinions on risk factors for recurrence in the
setting of WBI (Tables 10 and 11).
For a select group of women there is evidence that
radiation therapy may offer little or no benefit. The
26
most compelling study, CALGB 9343 (Intergroup
trial), randomized women over 70 years old with
stage 1 breast cancer to tamoxifen plus radiation
therapy or tamoxifen alone.31 The updated results
reported 90% of patients in the tamoxifen only arm
compared with 98% in the tamoxifen plus radiation
arm were free from locoregional recurrence.
Although the 8% difference was significant, the
study concludes that tamoxifen remains a reasonable
option for women age 70 years and older with
ER-positive early-stage breast cancer due to the
similar rate of metastatic disease and overall survival.
A second study from Princess Margaret Hospital
evaluated 769 women over the age of 50 with early
stage breast cancer who received either tamoxifen
or tamoxifen plus whole breast radiation.32 In a
subset of women over the age of 60 with tumors
<1cm the risk of relapse was 2.6% versus 0%, which
was not statistically significant. However, this
was an unplanned analysis with a short follow-up.
Regardless, the National Comprehensive Cancer
Network (NCCN) guidelines state that radiation
therapy may not always be necessary for women
70 years or older with Stage 1 breast cancer that
is hormone receptor positive in those that receive
endocrine therapy. An aid to possibly help in this
decision is a nomagram available online (www.
mdanderson.org/RadiationBenefitPredictor) that is
based on 7,400 women over the age of 70 years that
would have been eligible for the CALGB study.33, 34
At PeaceHealth all the women who are treated
for breast cancer are discussed prospectively at a
multidisciplinary tumor conference. The group’s
recommendations are then presented to the patient
to allow a well-informed decision regarding their
treatment.
www.peacehealth.org
Fall 2013
Table 10: Patient Selection for Accelerated Partial Breast Irradiation (APBI)
According to the American Society for Therapeutic Radiology and Oncology (ASTRO)
Series
Age
Tumor Size
Histology
Lymph
Nodes
Margins
American Society of
Breast Surgeons
≥ 50 yrs
< 3 cm
Invasive
ductal
Negative
No tumor
on ink
American
Brachytherapy Society
≥ 45 yrs
< 3 cm
Invasive
ductals
Negative
No tumor
on ink
Table 11: Patient Selection for Accelerated Partial Breast Irradiation (APBI)
According to the American Society of Breast Surgeons and American Brachytherapy Society
Criteria used
Suitable
Cautionary
Unsuitable
Age
≥ 60 yrs
50-59 yrs
< 50 yrs
Tumor size
Up to 2 cm
2 to 3 cm
> 3 cm
Surgical margins
≥ 2 mm
< 2mm
positive
Lymph node
Negative
-
Positive
Estrogen receptor
Positive
-
Negative
Lymphovascular invasion
Negative
Focal
Extensive
Volume 6, Number 1
Exceptional Medicine
27
What is the
Role of Research?
P
eaceHealth Cancer Center has 27 years of experience in offering breast
cancer studies to the women and men of Clark, Cowlitz, and surrounding
counties. The cancer research team works every day to identify patients who
are eligible for possible participation on a clinical trial. All newly diagnosed
breast cancer patients and new patient consults at PeaceHealth are screened
by the research staff and if eligible for a study are offered participation in a
national clinical trial.
In 1986 the first patient to enroll on a national
clinical trial at PHSW was a breast cancer
treatment patient. Following the first enrolled
patient and continuing for the last 27 years,
PHSW and our breast cancer patients have
participated in hundreds of breast studies.
Throughout the years, PeaceHealth has been a
leader in the advancement of new diagnostic
techniques and treatments including: sentinel
node biopsies vs. full axillary node dissections,
tamoxifen for hormone receptor positive tumors,
Oncotype DX to determine recurrence risk,
Herceptin for HER-2 positive tumors, partial
breast irradiation following lumpectomy, targeted
28
therapies for breast cancer, and circulating tumor
cells to indicate appropriate therapy.
The research staff at PeaceHealth is passionate
about supporting breast cancer research and
offering patients the opportunity to participate
in trials to find new treatments or improve on
current research-proven therapies. PeaceHealth is
an active member of Western Oncology Research
Consortium (WORC), a National Cancer Institute
accredited consortium of local healthcare systems
and providers offering clinical trials in cancer
prevention, symptom control and treatments,
advancing the knowledge of cancer and
improving the health of cancer patients in the
www.peacehealth.org
Fall 2013
Northwest. Through WORC, PHSW is a member
of the major national research bases including
Southwest Oncology Group (SWOG), Radiation
Therapy Oncology Group (RTOG), North Central
Cancer Treatment Group (NCCTG), National
Surgical Adjuvant Breast and Bowel Project
(NSABP), among others.
As a member of all of the major research bases we
are able to offer national treatment trials with new
chemotherapy medications, targeted medications,
new combinations of chemotherapy treatments,
new radiation modalities, and new surgical
treatments. We also offer clinical trials that
address prevention of breast cancer and cancer
recurrence. Other clinical trials are conducted to
look at ways to control symptoms or manage the
side effects of cancer treatment. Quality of life
studies are also offered that look at the ways that
cancer treatments affect the patients well-being.
For women who are undergoing breast biopsy,
PeaceHealth is currently offering participation
in a trial that is developing a test for the early
detection of breast cancer using proteins that are
present in human tear samples. After the patient
consents to participation, proteins are collected
from the patient’s eye with a simple saline eye
flush. This study may discover new ways to
screen patients for breast tumors in the future.
Volume 6, Number 1
The cancer treatments that we use today were
developed based on knowledge gained from
previous clinical trials. As a result, people
treated for breast cancer, as well as other types
of cancer, are living longer. Participation in a
clinical trial not only offers the patient the most
up to date treatment, but also offers the patient
a way to contribute to the future of cancer care.
Breast cancer clinical trials have always led
the way in research at PHSW. We are currently
accruing patients to seven different breast cancer
treatment trials and two cancer control studies.
The first cancer control study is a study of the
effects of exercise on cancer related fatigue. The
second is assessing vitamin D in premenopausal
women at high risk for breast cancer.
PeaceHealth remains on the cutting edge of
breast cancer diagnosis, treatment, and follow-up
care using research-proven therapies to benefit
our community. We thank our patients who have
participated in these trials. Without them, this
life-saving research would not be possible. There
is still much work to be done and more exciting
discoveries to be made. Contact PHSW Cancer
Research for more information about current
clinical trials or to ask about participation on a
clinical trial, 360-514-3940.
Exceptional Medicine
29
Selected Breast Clinical Trials, Biopsy Techniques
A)
Decreasing extent of axillary surgery
1.
ACOSOG Z1011( 2012) …sentinel nodal surgery better than formal axillary node dissection in early
breast cancer when breast preservation planned(no data for mastectomy or partial breast irradiation
patients)
2.
EORTC AMAROS (After Mapping Axilla, Radiation or Surgery?) 2013 …large European trial found
that even in biopsy proven node positive patients, radiation to axilla associated with similar local
control and fewer side effects than surgical axillary dissection
3.
ACOSOG Z1071(2013) …select patients with biopsy proven nodal metastasis by core or FNA convert
to negative in 40% of cases with chemotherapy, and sentinel node can be safely done with 90%
accuracy following neoadjuvant therapy. Supports concept of sentinel node surgery after neoadjuvant
therapy
B)
Is it possible to decrease the inconvenience of radiation therapy?
4.
NSABP 39(completed, awaiting results) …for tumors less than 3 cm in size with 1-3 nodes, can
radiation be decreased to part of the breast & completed in 1 week ?
5.
RTOG 1005(in progress) …can whole breast irradiation be given over a shorter course of 3 weeks
instead of the 5 weeks usually done (hypofractionation)
6.
NSABP 51(in progress) …In which of those 40% of patients that convert from positive to negative
with neoadjuvant therapy, can radiation be safely omitted?
C)
Is it possible that the discomfort of needle biopsy may be replaced by even less invasive
techniques?
7.
D)
Are there instances where the need for surgery can be completely eliminated?
8.
30
The “tear trial” ( in progress) …as far out as it seems, there is a question whether there may be
changes of a molecular nature in tears which may correlate with the biology of cancer enough to be
useful
NSABP concept schema (Dr Thomas Julian) …concept working way through NSABP for new
trial for patients whose cancers have had complete response to treatment using triple imaging
(mammography, ultrasound,& MRI) with core biopsy
www.peacehealth.org
Fall 2013
What is the
PeaceHealth Experience?
NURSE NAVIGATORS – A TEAM APPROACH TO CANCER CARE
A
dvances and improvements in cancer treatment have helped to save
millions of lives during the last 30 years. Yet, it is easy for a patient
newly diagnosed with cancer to feel overwhelmed and lost, adrift in a
rapidly changing, complex, and unfamiliar medical system.
Nurse Navigators help patients understand
their diagnosis and overcome their fears. Our
Nurse Navigators provide educational resources
to assist patients in making informed medical
decisions. Nurse Navigators facilitate referrals
to doctors’ appointments, procedures, other
disciplines, and make sure patients stay on track
with their treatment plans.
Volume 6, Number 1
PeaceHealth Nurse Navigators identify patient
goals during treatment and place special
consideration and emphasis on quality of life
by offering a listening ear, compassion, and
emotional support. Like compasses that provide
direction, nurse navigators are registered nurses
specializing in oncology who help guide patients
and their loved ones through the health care
system during the cancer experience.
Exceptional Medicine
31
CONCLUSION
A diagnosis of cancer will forever change a
person’s life. Here at the PeaceHealth Kearney
Breast Centers in Vancouver and Longview,
our teams of dedicated professionals focus on
every aspect of care for women and men with
breast cancer. From diagnosis through surgery
and all phases of treatment, we are here for you
and your loved ones. Our staff is continually
seeking ways to improve the care we deliver
through ongoing professional training and
quality improvement projects. Through access
to clinical research trials, we are partnering with
our patients and our community to constantly
improve the survivability and quality of life for
patients with cancer.
The PeaceHealth Mission:
We carry on the healing mission of Jesus Christ
by promoting personal and community health, relieving pain and suffering,
and treating each person in a loving and caring way.
Our vision:
Every person receives safe, compassionate care; every time, every touch.
32
www.peacehealth.org
Fall 2013
References
1.
National Cancer Institute Breast Cancer Risk Assessment Tool
2.
Esserman LJ, Shieh Y, Rutgers EJ, Knauer M, Retèl VP, Mook S,
Glas AM, Moore DH, Linn S, van Leeuwen FE, van ‘t Veer LJ .
Impact of mammographic screening on the detection of good
and poor prognosis breast cancers. Breast Cancer Res Treat. 2011
Dec;130(3):725-34. Epub 2011 Sep 4.
3.
American Journal of Roentgenology. 2011;196: W112-W116
4.
Navarro Silvera S, and Rohan T. Benign proliferative epithelial
disorders of the breast: a review of the epidemiologic evidence,
(2007) Breast Cancer Res Treat, 17 August 2007, Springer
Science+Business Media, LLC 2007
5.
Dupont WD, Parl FF, Hartmann WH, Brinton LA, Winfield AC,
Worrell JA, Schuyler PA, Plummer WD. Breast cancer risk associated
with proliferative breast disease and atypical hyperplasia. Cancer.
1993 Feb 15;71(4):1258-65.
6.
Eby P, Ochsner J, DeMartini W, Allison K, Peacock S, Lehman C.
Frequency and Upgrade Rates of Atypical Ductal Hyperplasia
Diagnosed at Stereotactic Vacuum Assisted Breast Biopsy:
9- Versus 11-Gauge. AJR 2009; 192:229–234
7.
American Joint Commission on Cancer Staging Manual,
Seventh edition, 2010, pages 358-360.
8.
American Joint Commission on Cancer Staging Manual,
Seventh edition, 2010, pages 371-373.
9.
Esserman LJ, Shieh Y, Rutgers EJ, Knauer M, Retèl VP, Mook S,
Glas AM, Moore DH, Linn S, van Leeuwen FE, van ‘t Veer LJ .
Impact of mammographic screening on the detection of good
and poor prognosis breast cancers. Breast Cancer Res Treat. 2011
Dec;130(3):725-34. Epub 2011 Sep 4.
10.
11.
12.
Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Davies
C, Godwin J, Gray R, Clarke M, Cutter D, Darby S, McGale P, Pan
HC, Taylor C, Wang YC, Dowsett M, Ingle J, Peto R. Relevance of
breast cancer hormone receptors and other factors to the efficacy
of adjuvant tamoxifen: patient-level meta-analysis of randomised
trials. Lancet. 2011;378(9793):771.
Davies C, Pan H, Godwin J, et al. Long-term effects of continuing
adjuvant tamoxifen to 10 years versus stopping at 5 years after
diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a
randomised trial. Lancet 2013; 381:805.
Gray RG, Rea D, Handley K, et al. aTTom: Long-term effects of
continuing adjuvant tamoxifen to 10 years versus stopping at 5
years in 6,953 women with early breast cancer. J Clin Oncol 2013; 31
(suppl; abstr 5).
13.
Dowsett M, Cuzick J, Ingle J, et al. Meta-analysis of breast
cancer outcomes in adjuvant trials of aromatase inhibitors versus
tamoxifen. J Clin Oncol 2010; 28:509.
14.
Moja L, Tagliabue L, Balduzzi S, Parmelli E, Pistotti V, Guarneri
V, D’Amico R. Trastuzumab containing regimens for early breast
cancer. Cochrane Database Syst Rev. 2012;4:CD006243.
15.
Clarke M, Collins R, Darby S, et al: Effects of radiotherapy and of
differences in the extent of surgery for early breast cancer on local
recurrence and 15-year survival: An overview of the randomised
trials. Lancet 366:2087- 2106, 2005
16.
Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby
S, McGale P, et al: Effect of radiotherapy after breast-conserving
surgery on 10-year recurrence and 15-year breast cancer death:
Meta-analysis of individual patient data for 10,801 women in 17
randomised trials. Lancet 378:1707-1716, 2011
17.
Fisher B, Anderson S, Bryant J, et al., Twenty-year follow-up of a
randomized trial comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation for the treatment of invasive breast
cancer., N. Engl. J. Med. 2002; 347(16):1233-41.
Volume 6, Number 1
18.
Van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results
of a randomized trial comparing breast-conserving therapy with
mastectomy: European Organization for Research and Treatment of
Cancer 10801 trial. J Natl Cancer Inst. 2000;92(14):1143-50.
19.
Freedman GM, Anderson PR, Li J et al. Intensity modulated
radiation therapy (IMRT) decreases acute skin toxicity for women
receiving radiation for breast cancer. Am J Clin Oncol. 2006
Feb;29(1):66-70.
20.
Qi XS, Hu A, Wang K, Newman F, Respiration induced heart motion
and indications of gated delivery for left-sided breast irradiation. Int
J Radiat Oncol Biol Phys. ;82(5):1605-11.
21.
Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of
hypofractionated radiation therapy for breast cancer. N Engl J Med.
2010;362(6):513-20
22.
Bentzen SM, Agrawal RK, Aird EG, et al. The UK Standardization
of Breast Radiotherapy (START) Trial A of radiotherapy
hypofractionation for treatment of early breast cancer: a
randomized trial. Lancet Oncol. 2008;9(4):331-41.
23.
Smith BD, Bentzen SM, Correa CR, et al. Fractionation for whole
breast irradiation: an American Society for Radiation Oncology
(ASTRO) evidence-based guideline. Int J Radiat Oncol Biol Phys.
2011;81(1):59-68
24.
Czechura T, Winchester DJ, Pesce C., Accelerated partial-breast
irradiation versus whole-breast irradiation for early-stage breast
cancer patients undergoing breast conservation, 2003-2010:
a report from the national cancer data base. Ann Surg Oncol.
2013;20(10):3223-32
25.
Polgár C, Fodor J, Major T, et al. Breast-conserving therapy with
partial or whole breast irradiation: Ten-year results of the Budapest
randomized trial. Radiother Oncol. 2013 Jun 3.
26.
Shah C, Badiyan S, Ben Wilkinson J, et al. Treatment Efficacy with
Accelerated Partial Breast Irradiation (APBI): Final Analysis of
the American Society of Breast Surgeons MammoSite(®) Breast
Brachytherapy Registry Trial. Ann Surg Oncol. 2013;20(10):3279-85.
27.
Veronesi U, Marubini E, Mariani L, et al. Radiotherapy after breastconserving surgery in small breast carcinoma: long-term results of a
randomized trial. Ann Oncol. 2001;12(7):997-1003
28.
Smith BD, Arthur DW, Buchholz TA, et al. Accelerated partial
breast irradiation consensus statement from the American Society
for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys.
2009;74(4):987-1001.
29.
American Society of Breast Surgeons website. American Society
of Breast Surgeons: Consensus Statement for Accelerated Partial
Breast Irradiation: 2011 Update. http://www.breastsurgeons.org/
statements/PDF_Statements/APBI.pdf. Accessed Sept. 9th, 2013.
30.
Shah C, Vicini F, Wazer DE, et al., The American Brachytherapy
Society consensus statement for accelerated partial breast
irradiation. Int J Radiat Oncol Biol Phys. 2011 Sep 1;81(1):59-68.
31.
Hughes KS, Schnaper LA, Berry D, et al., Lumpectomy plus
tamoxifen with or without irradiation in women 70 years of age or
older with early breast cancer. J Clin Oncol. 2013;31(19):2382-7
32.
Anthony W. Fyles, M.D., David R. McCready, M.D., Lee A. Manchul,
M.D., et al. Tamoxifen with or without Breast Irradiation in Women
50 Years of Age or Older with Early Breast CancerN Engl J Med
2004; 351:963-970.
33.
Albert JM, Liu DD, Shen Y, et al: Nomogram to predict the benefit
of radiation for older patients with breast cancer treated with
conservative surgery. J Clin Oncol 30:2837-2843, 2012
34.
Albert JM, Pan IW, Shih YC, et al: Effectiveness of radiation for
prevention of mastectomy in older breast cancer patients treated
with conservative surgery. Cancer 118:4642-4651, 2012
Exceptional Medicine
33
PO Box 1600
Vancouver, WA 98668