Download Health-Process-Evidence-based Clinical Practice

Health-Process-Evidencebased Clinical Practice
Guidelines Breast Cancer
Locally Advance Breast Cancer
Locally Recurrent Breast Cancer
Metastatic Breast Cancer
Harvey A. Balucating, MD
A. Overview of the Problem
• Concept
B. General Management Guidelines
• Clinical Diagnosis
• Paraclinical Diagnosis
• Prognosis
• Treatment Algorithm
Clinical Questions
1a. What is a operational concept of
locally advance breast cancers?
Definition
- Not considered Early Breast Cancer
- with no evidence of metastasis
- This will comprise T4 or Stage III - B
Clinical Questions
1b. What is a operational concept of
locally recurrent breast cancer?
Definition
- reappearance of tumor within the
operative site after surgical treatment
(i.e., mastectomy or lumpectomy)
Clinical Questions
1c. What is a operational concept of
metastatic breast cancer?
Definition
- spread of cancer from the primary site
(breast cancer) and formation of tumor in
distant site
Clinical Questions
2a. What are reliable signs and symptoms (more
than 90% certainty) that will indicate that a
patient had locally advance breast cancer?
Ans:
– Breast cancer with T4 ( tumor of any size with direct
extension to the chest wall (not including pectoralis
muscle) or skin confined to the same breast (edema,
ulceraqtion, satellite nodule) or inflammatory
carcinoma; with no evidence of metastasis
Clinical Questions
2a. What are reliable signs and symptoms (more
than 90% certainty) that will indicate that a
patient had locally recurrent breast cancer?
Ans:
– Reappearance of tumor (Breast cancer) after surgical
treatment (mastectomy or lumpectomy)
Clinical Questions
2a. What are reliable signs and symptoms (more
than 90% certainty) that will indicate that a
patient had metastatic breast cancer?
Ans:
Breast Cancer
General Management
Guidelines
•Clinical Diagnosis
•Paraclinical Diagnosis
•Staging and Prognostication
•Treatment
I. Clinical Diagnosis
Breast Cancer
EARLY
LOCALLY ADVANCE
SURGICAL
TREATMENT
LOCALLY RECURRENT
METASTATIC
Clinical Questions
3a. If a paraclinical diagnostic procedure is needed
in a patient with locally advance breast cancer,
what is the most cost-effective procedure to do?
Benefit
Risk
FNAB
++
Pain +
Bleeding
+
Available
Core
Needle
+++
Pain ++
Bleeding
++
Available
Open
Biopsy
++++
Pain +++
Bleeding
+++
Available
Options
Cost
Availability
Ans.
FNAB is the standard biopsy procedure for any
palpable breast mass
Core needle is done next when FNAB yields nondiagnostic results
Open biopsy if core needle biopsy failed
Clinical Questions
3b. If a paraclinical diagnostic procedure is needed
in a patient with locally recurrent breast cancer,
what is the most cost-effective procedure to do?
Ans:
- Physical examination alone adequately
detects locoregional recurrence due to breast
cancer in most cases
- Cytologic or histologic documentation of
recurrent disease should be obtained whenever
possible, prior to active treatment
- Core Needle Biopsy is the initial diagnostic
procedure in breasr cancer patient with palpable
locoregional recurrence
Clinical Questions
3c. If a paraclinical diagnostic procedure is needed
in a patient with metastatic breast cancer, what
is the most cost-effective procedure to do?
Ans:
-
Clinical Questions
4. What is the 5 – year survival rate of
the following:
• Locally advance breast cancer
48%
• Metastatic breast cancer Locally recurrent breast
cancer
•
18%
Treatment
LOCALLY ADVANCED
BREAST CARCINOMA
PRE-OP CHEMOTX
RESPONSE
LOCOREGIONAL
NO RESPONSE
ADDITIONAL CHEMOTX
AND/OR RT
NO RESPONSE
NEXT SLIDE
INDIVIDUALIZED TX
LOCOREGIONAL
TOTAL MASTECTOMY +
SURGICAL AXILLARY
STAGING + RT + DELAYED
BREAST RECONSTRUCTION
LUMPECTOMY +
SURGICAL AXILLARY
STAGING + RT + DELAYED
BREAST RECONSTRUCTION
HIGH DOSE RT ALONE
CHEMOTX + HORMONAL TX
IF Er (+),
LOCALLY RECURRENT
METASTATIC WORK-UP
(+)
METASTATIC
BREAST CA
(-)
INITIALLY TREATED
WITH MASTECTOMY
INITIALLY TREATED WITH
LUMPECTOMY WITH RT
SURGICAL RESECTION +
RT (IF POSSIBLE)
CHEMOTX
MASTECTOMY
METASTATIC BREAST CA
ER/PR POSITIVE OR
BONE/SOFT TISSUE ONLY
OR ASYMPTOMATIC
VISCERAL
PRIOR ANTIESTROGEN
WITHIN 1 YEAR
ER/PR NEGATIVE
OR SYMPTOMATIC
VISCERAL OR HORMONE
REFRACTORY
NO PRIOR ANTIESTROGEN
OR 1 YEAR OFF
ANTIESTROGEN
SECOND-LINE HORMONAL
THERAPY
A
B
A
POSTMENOPAUSAL
PREMENOPAUSAL
AROMATASE
INHIBITOR OR
ANTIESTROGEN
OVARIAN ABLATION
OR SUPPRESSION
+ HORMONAL TX
OR ANTIESTROGEN
B
HER-2b OVEREXPRESSED
HER-2b NOT OVEREXPRESSED
TRASTUZUMAB +
CHEMOTX
CHEMOTX
NO RESPONSE TO 3
SEQUENTIAL REGIMENS
OR ECOG PERFORMANCE
STATUS > 3
CONSIDER NO FIRHTER
CYTOTOXIC THERAPY
(PALLIATIVE CARE)