Recent Advances in the Treatment of Breast Cancer

RECENT ADVANCES IN THE TREATMENT OF BREAST CANCER Djoko H. Hermanto Hematology-Medical Oncology Division, Department of Internal Medicine Faculty of Medicine, Brawijaya University - Dr. Saiful Anwar General Hospital Malang

Individualizing Treatment of Women with Breast Cancer (BC) Factors that affects treatment option:  Menopausal status: premenopausal or post menopausal  Biological Age: younger or older patients  Molecular subtype: ER, PR, HER2, (Ki-67) status (Luminal A, lum B,         

HER2+, Triple negative) T,N Stage: types of surgery, neo-adjuvant or adjuvant treatment Number of lymph nodes involvement Pre-invasive or invasive BC DCIS or LCIS Inflammatory / non-inflammatory Performance status Co morbidities factors Previous therapy and toxicities Patient preference 1. NCCN guidelines Version 1.2014 2. Goldhirsch A, et al. Annals of Oncology 2013;24: 2206–2223 3. Cardoso F, et al. Annals of Oncology 2014; 00: 1–18.

Histological & Molecular subtypes of BC

TNM Staging System for Breast Cancer

Early BC refers to BC in stages 0, I and II, Locally Advanced BC refers to BC in stages IIIA – IIIC, Advanced or Metastatic BC refers to BC in stages IV, at the time of diagnosis

1. NCCN Guidelines version 3.2014 2. Kalogerakos K, et al. Cancer Therapy 2008;6:463-476

New Approach to Breast Cancer  Breast cancer treatment needs multidisciplinary

approach and team  Good relation between Radiologists, Pathologists,

Surgeons, Medical oncologists and Radiotherapist is needed to choose the best treatment options for every patients  Trained nurses needed to help patient and

physician in diagnosis and treatment  Supportive group and programs are needed to

increase information of patient and her quality of life

Breast Cancer: Treatment Options  Management of BC often involves more than one

approach  Surgical option is the mainstay of the treatment of EBC1  Breast-conserving surgery (lumpectomy, or segmented

mastectomy), followed by radiation therapy2; or  Mastectomy (simple mastectomy with sentinel biopsy or modified radical mastectomy)2.

 Adjuvant Radiation therapy  Systemic therapy: neoadjuvant/ adjuvant chemotherapy.  Targeted therapy: Endocrine therapy, Anti HER2

1. Ring A, et al. British Journal of Cancer 2011;105: 189–193 2. NCCN version 3.2014

Surgical option  Breast-Conserving Surgery (BCS) has become the standard

treatment for EBC.  Indications: Stage I or Stage II Breast Cancer (localized tumor)  

  

Tumor not fixed to overlying skin or to underlying muscle Negative surgical margins No diffuse, inflammatory or multicentric cancer No malignant appearing mammographic abnormalities after surgery No previous radiation (prevents further Breast Radiation Therapy)

 Lymph node involvement is not a contraindication 

Lnn. must not be fixed to other lymph nodes and to surrounding tissue

 Invasive ductal and lobular cancer not contraindication 

Tumor must not be diffuse  Requires that negative surgical margins are achieved 1. Cordeiro. N Engl J Med 2008;359:1590-601 2. Morrow (2002) CA Cancer J Clin 2002;52(5): 277-300

Different methods of mammoplasty used to fill defects after wide lumpectomies makes better cosmetic results

Adjuvant Radiation Therapy  Adjuvant radiotherapy is the current standard of care for:  Patients with EBC following BCS, and  Patients with a high risk of local recurrence following

mastectomy.1

 According to the Oxford overview analysis (EBCTCG,

2005a): in women undergoing BCS followed by radiation vs surgery alone, 5-year local recurrence risks were 7% vs 26% (2P