1. Breast Cancer Treatment Three parts –Local/regional therapy –Systemic therapy –Prevention Weigh risk/benefit ratio Timing Overall impact on survival

2. Local/regional therapy Surgery –Halsted Radical Mastectomy –Modified Radical Mastectomy ( Patey) –Total Mastectomy –Lumpectomy –LumpAx Radiation – reduces LR ½- ¾ and decreases deaths for ¼ recurrences prevented post mastectomy –Whole breast –5 field –Partial breast ( mammosite)

3. Systemic therapy Prognostic signs –Size, nodes (sentinel vs regular), grade Predictive signs –ER, PR, Ki 67, Her-2, etc. Two major types –Cytotoxic – reduces death rate about 1/3 Antracyline based Taxane based Herceptin enhancement –Hormonal Tamoxifen (SERM) – reduces death rate about 1/4 Aromatase Inhibitors – reduces death rate about 1/3 Ovarian ablation, etc.

4. Prevention TAM – reduces incidence of new cancers 49% if first ca was ER+ AI’s – reduce incidence of new cancers post-menopausally by 75-78% if first ca was ER+ PMastectomy reduces risk by > 95%

5. Case 1 47 y.o. WF 1.2 cm IDC detected on annual mammo –MA 11 –PG 31 –Fam hx – Mother @ 51 –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

6. Case 1 Path –Margins negative –Nodes negative –ER+ PR+ –Her 2 – –Ki67 18% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

7. Case 1 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

8. Case 2 27 y.o. WF 2.2 cm ILC detected on SBE –MA 9 –PG none –Fam hx – M and 2 Sisters –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

9. Case 2 Path –Margins negative –Nodes 1/6+ –ER- PR- –Her 2 + –Ki67 48% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+ herceptin f)b+ herceptin g)d+c + herceptin And what about prevention?

10. Case 2 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

11. Case 3 53 y.o. WF 0.6 cm IDC with DCIS detected on annual mammo –MA 11 –PG 31 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

12. Case 3 Path –Margins negative –Nodes negative –ER+ PR+ –Her 2 – –Ki67 18% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

13. Case 3 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

14. Case 4 83 y.o. WF with DCIS detected on annual mammo –MA 11 –PG 22 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

15. Case 4 Path –Margins negative –Nodes ? –ER+ PR+ –Her 2 – –Ki67 18% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

16. Case 4 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

17. Case 5 53 y.o. WF 6cm IDC with DCIS detected on PE –MA 11 –PG 31 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node positive on exam –Erythema and edema on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

18. Case 5 Path –Margins close –Nodes 5/23 + –ER+ PR- –Her 2 = –Ki67 63% Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

19. Case 5 Which order to Rx? a)Surgery, radiation, chemo b)Radiation, chemo, surgery c)Chemo, radiation, surgery d)Chemo, surgery, radiation e)Doesn’t make a difference

20. Case 6 53 y.o. WF with LCIS detected on excision of FA –MA 11 –PG 31 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

21. Case 6 Path –Margins + –Nodes ? Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?

22. Case 7 55 y.o. BF with ADH found on core bx –MA 9 –PG 21 –Fam hx – none –No prior bx –No other lesions in either breast on exam or imaging –No c/o systemic disease –Node negative on exam –No grave signs on exam Local therapy options a)Lumpectomy b)Lumpectomy and Rad c)LumpAx Rad d)TM e)MRM f)HRM g)TM Rad h)MRM Rad i)HRM Rad

23. Case 7 Path –Margins + –Nodes ? Systemic Rx a)AC x 4 b)AC x 4 and T x 4 c)Tam x 5 yrs d)AI x 5 yrs e)a+c f)b+c g)d+c And what about prevention?