From Queens Library's expert-led panel, Cancer Awareness: What You Need to Know, featuring professionals from New York Hospital Queens, North Shore LIJ, the American Cancer Society, and the Leukemia and Lymphoma Society

1. Breast Cancer in 2012
Jane Carleton, M.D.
Monter Cancer Center
North Shore-LIJ

2. Breast Cancer in the U.S.
 1 in 8 women in the U.S. will be diagnosed
with breast cancer in their lifetime
 Hereditary vs. environmental causes
 Higher incidence of breast cancer in
industrial areas, including most of the east
coast, west coast and around the great
lakes
 Is NYC or Long Island a hot spot?

3. Hereditary Causes of Breast Cancer
 BRCA1 and BRCA2
 Increased risk of breast and ovarian cancer
 Only found in ~5% of breast cancer patients

More common in certain groups such as
Ashkenazi Jewish population
 Only about 15% of breast cancer is clearly
linked with a strong family history and
possible inherited risk factor

4. Screening for Breast CA
 Annual mammogram

Starting at 40 or 50?
 Should it be every other year?
 Current guidelines: start at 40 and every year
 Sonogram for patients with dense breast tissue
or for additional evaluation (cyst vs nodule)
 MRI only in selected patients

Patients with BRCA mutation starting at 25
 Patients newly diagnosed with breast cancer

5. Evaluating a Nodule
 A needle biopsy is the preferred method to
evaluate an abnormality found on mammogram
or sonogram
 Needle biopsies are usually done by the
radiologist as an outpatient and only require
local anesthesia
 The majority of biopsies are benign
 Surgical biopsies should only be done when
further evaluation or treatment is required

6. Multidisciplinary Teams for Breast
Cancer Treatment
 Radiologist
 Breast Surgeon
 Medical Oncologist
 Radiation Oncologist
 Genetics Counselor

7. Surgery for Breast Cancer
 Lumpectomy vs mastectomy
 Sentinel lymph node evaluation
 Only a few key lymph nodes removed
 Axillary lymph node dissection

Done when a sentinel lymph node is positive
or if suspicious lymph nodes are seen or felt
prior to surgery

8. Reconstructive Surgery
 By law must be offered and covered by
insurance for women having a mastectomy
 Reconstructive surgery is done by a plastic
surgeon working with the breast surgeon
 Can be done at the same time as mastectomy
 Implants
 With or without lattisimus muscle flap
 Autologous tissue recreating breasts
 DIEP Flap

Tram Flap

9. Pathology
 The biopsy and the surgery give us critical
information about the tumor
 Is the tumor sensitive to hormones
 Estrogen receptors
 Progesterone receptors
 Her-2/neu

About 15-20% of breast cancer have this protein
 Triple Negative

ER negative, PR negative, Her-2/neu negative
 Lymph node status

10. Breast Cancer Staging
 Stage 0: noninvasive cancer (DCIS)
 Stage I: tumor is <2 cm
 Stage II: tumor is larger than 2 cm and/or
there are 1-3 lymph nodes involved
 Stage III: tumor is more extensive and/or
more lymph nodes are involved
 Stage IV: the tumor has spread to distant
lymph nodes or organs

11. Why is Stage Important?
 Early stage breast cancer may only need
hormonal treatment
 Lymph node involvement generally means
chemotherapy should be given
 Larger tumors may need radiation
 Is the treatment goal curative or palliative
 Stages 0-III goal is curative
 Stage IV cancer is not curable but is treatable

12. Radiology Imaging Studies to
Determine Extent of Cancer
 Chest Xray
 Bone scan
 CT scan of chest, abdomen and pelvis
 CT or MRI of the brain
 Pet/CT scan

13. Treatment for Breast Cancer
 Hormonal Therapy
 Offered when tumor is hormone sensitive
 Chemotherapy
 Important to individualize who really needs it
 Targeted Therapy
 Her-2/neu positive breast cancer

14. Hormonal Therapy
 Breast tumors have receptors for estrogen and/or
progesterone 85% of the time
 Tamoxifen

Blocks the estrogen receptor
 Works in both premenopausal and postmenopausal
women and in men
 Aromatase inhibitors
 Anastrazole (Arimidex)

Letrozole (Femara)

Exemestane (Aromasin)
 These medicines lower estrogen levels in post-
menopausal women

15. Tamoxifen
 Used for 40 years
 Lowers chance of breast cancer
recurrence by ~50%
 Generally well tolerated
 Side effects include hot flashes, changes
in periods, vaginal dryness or discharge
 Risks include cataracts, blood clots
(DVT/PE), stroke, endometrial cancer,
uterine sarcoma

16. Aromatase Inhibitors
 Available since the 1990s
 Arimidex was compared to Tamoxifen and
shown to be slightly more effective with a
better side effect profile (reported in 2002)
 No blood clots, uterine cancer or cataracts
 Increased risk of bone loss and fracture
 Increased risk of joint pain

17. Chemotherapy & Hormonal Therapy
 Some patients will get only hormonal
therapy (patients with smaller, lower risk
breast cancers)
 Some patients will get only chemotherapy
(estrogen/progesterone negative breast
cancer)
 Many patients will receive both types of
therapy to maximize the cure rate

18. When Do We Use Chemotherapy?
 Tumor is larger than 1 cm (sometimes)
 Lymph nodes are involved
 The tumor appears aggressive

Poorly differentiated

Negative hormone receptors

Her-2/neu positive

High Ki-67 (marker of aggression)
 The Oncotype DX assay
 Evaluates the tumor’s DNA
 Used to determine when chemotherapy will be beneficial
 Gives a score to predict risk of recurrence

19. How We Choose Chemotherapy
 Chemotherapy has been tested in many
clinical trials and certain drugs have come
to be the mainstay of treatment, including
adriamycin, cytoxan, paclitaxel (Taxol),
docetaxel (Taxotere)
 Most breast cancer regimens use 2-3
drugs given over 4-6 cycles (doses)
 The characteristics of the cancer may
determine the regimen recommended

20. Standard Chemotherapy Regimens
 Taxotere and Cytoxan (4-6 cycles)
 Adriamycin and Cytoxan (four cycles)
followed by Taxol (four cycles or 12 wks)
 Taxotere, Adriamycin and Cytoxan (6
cycles)
 CMF – Cytoxan, Methotrexate and 5-FU
 An older less effective regimen

21. Targeted Therapy: Her-2/neu
 Her-2/neu is a protein that some cancers have
that can make the cancer more aggressive
 About 15-20% of breast cancers are considered
Her-2/neu positive
 Trastuzumab (Herceptin) is a monoclonal
antibody that binds to Her-2/neu on the outside
of the cell
 Clinical studies showed that patients who were
given Trastuzumab in addition to chemotherapy
had a 50% improvement in their cure rate

22. Who gets Trastuzumab?
 Trastuzumab (Herceptin) is indicated for patients
who are strongly Her-2/neu positive
 A national clinical trial will study if patients who
are more weakly positive will benefit from
Trastuzumab as well (NSABP B-47)
 It may also benefit patients with DCIS when
given with radiation (NSABP B-43)

23. Other Her-2/neu Drugs
 Lapatinib (pill) that binds to Her-2/neu
inside the cell
 Pertuzumab (Perjeta) FDA approved in
2012 to be used with Trastuzumab and
Taxotere in metastatic breast cancer that
has not previously been treated

24. Other Targeted Therapies
 Bevacizumab (Avastin)
 T-DM1 (Trastuzumab linked to DM1, a
chemotherapy agent)
 PARP inhibitors are being developed and
are currently being studied in clinical trials.
They may play an important role in “triple
negative” breast cancer

25. Bevacizumab
 Bevacizumab (Avastin) is a monoclonal antibody
that binds to VEGF (vascular endothelial growth
factor)
 The goal is anti-angiogenesis, or to block new
blood vessel formation
 The drug is FDA approved for use in
combination with chemotherapy for metastatic
lung cancer and colon cancer and had been
approved for metastatic breast cancer
 Breast cancer approval rescinded this year

26. Bevacizumab in Breast Cancer
 FDA approval for breast cancer rescinded when
studies showed that while there was some
improvement in the response to chemotherapy
there was no improvement in overall survival,
raising the question of how effective the drug
really is
 Further studies need to be done to establish the
role of this drug ( e.g. NSABP B-46 for early
stage breast cancer comparing TC vs. TAC vs.
TC + Bev)

27. Radiation Therapy
 Used for patients who have had a
lumpectomy to improve local control
 Used for patients who have had a
mastectomy if the tumor was large or
there were many lymph nodes involved
 Used to treat a local recurrence
 Used in metastatic disease to decrease
pain or symptoms in a particular spot

28. Genetic Counseling
 Recommended for patients newly diagnosed
with breast cancer if there is a greater than
standard risk of having an inherited gene for
breast cancer
 Two or more close relatives with breast cancer
 Any close female relative with ovarian cancer
 Ashkenazi Jewish
 Not done routinely as expensive and chance of
gene is low unless family history is strongly
positive

29. Follow Up
 Regular doctor appointments

Medical oncologist (2-4 times a year)
 Surgical oncologist (1-2 times a year)
 Routine blood work
 Annual diagnostic mammogram
 Annual sonogram if dense breast tissue
 Annual breast MRI

Often ordered by the breast surgeons

Not accepted as a routine test on a national level

30. Where Do We Stand?
 85% of all women who are diagnosed with
breast cancer will die from a non cancer related
cause
 The incidence of breast cancer has dropped in
the last ten years (especially since estrogen
therapy for postmenopausal women no longer
being offered as standard therapy for years)
 More breast cancer is being detected in earlier
stages, improving the chance of cure
 New drugs continue to be developed which will
further improve our success in treating breast
cancer