1. Treatment Overview: The Multidisciplinary Team
Julie R. Gralow, M.D.
Director, Breast Medical Oncology, Seattle Cancer Care Alliance
Professor, Medical Oncology, University of Washington School of Medicine
Member, Clinical Division, Fred Hutchinson Cancer Research Center

2. Breast Cancer Treatment: A Multidisciplinary Team Approach
Radiology
Pathology
Surgery
Radiation Oncology
Medical Oncology
Fighting the Crab – Kiev, Ukraine

3. Personalized Cancer Medicine
New Strategies in Treating Breast Cancer:
Better Targeting
Individualized Approaches

4. Cancer Treatment: Defining the Cancer
The first step in designing the treatment plan is carefully defining the cancer
Clinical examination
Radiology tests
Pathology tests
Blood tests

5. Diagnosing the Cancer: Ultrasound-Guided Breast Biopsy

6. Defining the Cancer: Pathology
Treatment recommendations are aided with the help of pathologic factors
Prognostic factors: aid in estimating likelihood of cancer recurrence and death
Predictive factors: predict likelihood of response to a given therapy

7. Invasive Breast Cancer
The First Step in Making a Treatment Plan for Breast Cancer: Defining the Cancer
Stage
Tumor size
Lymph node status
Metastatic sites
Grade
Surgical margins
Tumor expression of genes and proteins
Estrogen receptor (ER)
Progesterone receptor (PR)
HER-2
Invasive Breast Cancer
Estrogen Receptor
HER-2

8. Defining the Cancer: Radiology
Radiologic imaging can help determine the location and spread of the cancer
Local extent
Regional lymph nodes
Distant spread (metastases)

9. Evaluating Extent of Local Disease: Breast Cancer
Mammogram: Area of abnormality extends over 60 mm

10. Staging for Distant Disease: Breast Cancer Multiple bone metastases
Patient A
Bone Scan
Multiple bone metastases
The most common sites of distant disease in breast cancer are the bones, liver and lungs

11. Breast Cancer Surgery Sometimes “less” surgery is better
Mastectomy vs. lumpectomy
Lymph node dissection vs. sentinel lymph node biopsy

12. Lumpectomy: Wire Localization of Non-Palpable, Imaging-Detected Breast Cancers

13. Lumpectomy Margin Evaluation: Inking the Tumor Specimen in the Operating Room

14. Sentinel Lymph Node Biopsy
sentinel node biopsy requires substantial technology, resources, and training
1. Inject around area of tumor with blue dye, radioactivity, or both
2. Track the lymphatic drainage of the tumor

15. Breast Cancer Radiation Therapy
The future: is “less” radiation sometimes better?
Whole breast versus partial breast radiation (brachytherapy)
Hypofractionation (shorter course)
3D conformal radiation planning

16. Indications for Radiation Therapy After Mastectomy
Tumor size > 5 cm
Inflammatory features or skin involvement
Multiple positive lymph nodes
Extracapsular lymph node extension
Positive surgical margins

17. Systemic Therapy for Breast Cancer
Endocrine Therapy
Chemotherapy
Biologically-targeted Therapy
New Strategies: Individualizing treatment to the cancer and the patient

18. Identifying New Targets in the Treatment of Breast Cancer
HER-2 Inhibitors
Metastasis Inhibitors
IGF-R Inhibitors
EGFR Inhibitors
MUC-1 Antibodies
Anti-Angiogenesis
Src Inhibitors
mTOR Inhibitors
Farnesyl Transferase Inhibitors
MEK Inhibitors
HIF Inhibitors
Cell Cycle Inhibitors
Aurora Kinase Inhibitors
HSP90 Inhibitors
Raf Inhibitors
Pro-apoptotic Drugs
Proteosome Inhibitors
Mdm2 Inhibitors
Kinesins
HDAC Inhibitors
Tubulin-interacting Agents
Death Receptors

19. Optimizing Health and Wellness After Treatment of Breast Cancer: Survivorship
Many breast cancer patients can look forward to a long life after treatment
Breast cancer patients and their health care team need to pay attention to all aspects of health and well-being
Team Survivor Northwest