TEAM APPROACH RECEIVES A PERSONAL MAKE‐OVER
C Benn
Women treated with breast cancer feel that their care is coordinated and not fragmented.
INTRODUCTION
• Fine tuning of breast cancer diagnosis, • Better understanding of tumour biology, • Increased therapeutic options in all 3 major treatment arms
• The only “I” that is not in TEAM , would be not keeping ones eye on the ball.
• Interdisciplinary communication from A‐Z, ensures safe patient care, and excellent cancer outcomes.
Screening: A cautious word
Health economics
No local guidelines
Assess your patients medical aid
Aware government units offering high standard of mammography
• Be careful of mobile units
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• Safest to start at 40
Risk Factors
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Sex Age
Hormones
Genetics
Exogenous
• Genetic Lotto
TRIPLE ASSESSMENT • Patients should have age appropriate ultrasound and mammographic investigation and (core) needle biopsy
• No diagnostic excision biopsies of breast masses unless a failed needle biopsy in terms of pathological information
• Cost of biopsy • Non rushed biopsy essential for all patients
Fine tuning of breast cancer diagnosis
• Digital mammography
• Use of tomography
• Ultrasound picks up masses , cysts and assesses lymph nodes
• Minimal radiation
• Core needle biopsies are gold standard
• Check costs: Not all cores are equal
Multi‐disciplinary Team
Peer review
• cancer surgeon, radiologist, pathologist, reconstructive surgeon, oncologist, radiation oncologist and psychologist and the general practitioner
Patient safety
Informing Patients
Communication
VIRTUAL BREAST CENTRE
• Telephonic advice • Referrals to appropriate facilities
• Public talks
• Medical CME’s
• Website
• Utilisation of funding
Helen Joseph Breast Unit
• The clinic manages 500‐700 patients each month in two weekly specialist clinics.
• The Centre has kept separate hospital records since 2008 • Seen and followed‐up more than 12,000 patients in that time.
• Based on the most recent statistics, approximately 3000 new patients are seen per year. 60% of these patients will have a consultation for free, or for less than $4.
Cosmopolitan Unit
• 65% black patients; 18% white, small bias Asian 9% (7%)
• This breakdown reflects Johannesburg
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61% stage 3 and 4
28% under age 45
8% under 35
12% over 75
HJH and NBC
• The 2 units see on average 25‐30 new breast cancer patients per week • 10 and 15 being diagnosed in the government based unit situated at the Helen Joseph Hospital ‐
The majority of the patients present as locally‐
advanced disease and are referred immediately for primary chemotherapy.
• A further 2‐3 patients will undergo Sentinel Lymph Node Biopsy each week, of which two‐
thirds are positive
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T1<2cm
T2 2‐5cm
T3 >5cm
T4 what is the cancer doing T4a‐ chest wall
T= tumour size
T4b‐ skin
T4c both
T4d inflammatory
Staging
• N1 <2cm or mobile
• N2 >2cm or fixed
• N3 internal mammary, supraclavicular
• M metastases
• Bone
• visceral
Understand
• Principles of treatment
• Physical characteristics and the personality of the cancer
• Could this small cancer be a psychopath
Pathological risk assessment
• TNM staging based on H&E staining, standardised grading, description of histological types, , lymph vascular invasion , Ki 67 , ER, PR, Her 2 neu
(including SISH, FISH) should be reported
• Determination of oestrogen receptor and progesterone receptor status is mandatory, preferably by immunohistochemistry
• Immunohistochemical determination of HER2 should also be performed
• With ambiguous her2 immunohistochemistry , in situ hybridisation (FISH) (SISH) to determine HER2 gene amplification should be considered
Staging and risk assessment
• Routine staging examinations should include physical examination , including liver enzymes, alk. phos., ca, menopausal status and bone density
• Only in high risk patients (N2 >= 4 pos lymph nodes; or T4 tumours; or with lab or clinical signs or symptoms suspicious for the presence of metastases) are CXR, ultrasound or bone scan appropriate
Tumour Markers
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Serum tumour markers a guide to aid treatment decisions and monitor response of not easily measurable disease in the metastatic breast cancer settings Not for screening or diagnosis
Don’t Miss…
PSYCHOLOGY and BREAST CANCER • Most patients experience psychological problems following the diagnosis of breast cancer. • 80% of patients will experience either a sub clinical depression or chronic fatigue Counsellors critical
3 Modalities
• Loco regional treatment
1. Surgery
2. Radiation therapy
• Systemic (oncology)
1. Chemotherapy
2. Endocrine therapy
3. Target therapy
4. Radiation
Nothing immediate about breast
cancer management
• Process started prior to
surgery
• Individualise patients
• Importance of age
• Dynamic process
dependent on team work
• Prepared to change
management
• Intra-operative
assessment
Altering breast cancer management
Young patients
Use of radiation therapy
Use of chemotherapy
Most important in surgical management
1. Planning
2. Procedure
3. Discuss
• Team of the radiologist and surgeon should meet
• Need to read the radiology report,
• Ultrasound in a specialist unit can determine whether there is cancer in the lymph nodes
Surgical Principles
• Rule 1: 1cm margin
• Rule 2: check the draining lymph nodes
Sentinel Lymph Node Biopsy in Breast Cancer
Carol Benn
Security Gate Sentinel
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If the cancer has spread to the sentinel…..
Will need chemo
cancer is in the sentinel plus 2 or outside gland
Will need radiation treatment
• Separate sentinel lymph node biopsies helps determine who should start with chemotherapy and which surgical and reconstructive procedures are safe
Technical Solutions
Radiological guided peri‐tumoural injection
Once you know if……….. • Sentinel is positive • You can determine what surgical procedures one should not offer the patient
• What reconstructive procedures one should not offer the patient
• The patient should be guided by safe surgery and reconstructive principles
Who should get a mastectomy
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Lobular carcinomas
Inflammatory carcinoma
Pagets
Multi‐centric carcinomas
• Big prostheses and small breast
Patient choice
Surgical Rules
• Same for breast conservation or mastectomy
• Surgery depends on breast and tumour size and position; lobular or ductal ca; radiation therapy; and nodal status
• Strictly clear surgical margins !
• Clip surgical beds in breast conservation
• Sentinel lymph node biopsy in node negative cancers and axillary sampling /dissection (>8 lymph nodes) merely for prognostic and treatment guidelines
MARGINS IN BREAST CANCER SURGERY • young age / positive margins are the most important risk factors for recurrence after breast conservation therapy
• 10 mm is the standard
• All about safety
• 10mm margin with breast conservation surgery equates to a 2‐4% loco‐regional recurrence
Leaving no margin for error
Reconstruction
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Breast reconstruction an intrinsic part of breast cancer treatment
Immediate reconstruction should be first choice
Skin sparing mastectomy safe and effective (leaving less than 1% of breast tissue)
Rule 1:Prostheses don’t radiate well
Implants and expanders are generally not compatible with radiation
Latissimus flaps are the choice to radiate on
Careful pre‐operative planning
Rule 2: Allow patients time to decide
Trend to immediate one stage reconstruction
Psychological intervention is critical • Breast cancer scars no longer depict a cross to bear continually reminding patients of their cancer
• Volume displacement and volume replacement
Rule 3: Oncology reigns supreme
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Patients receiving adjuvant radiation therapy or primary chemotherapy should have multidisciplinary discussions to ensure the safest reconstructive options
Oncology surgery reigns supreme
Implants and expanders are generally not compatible with radiation
Latissimus flaps are the choice to radiate on
Careful pre‐operative planning
Rule 4: Latissimus flaps are Radiation Resistant
There are no rules ….only guidelines
How Much
more is better than less
Skin sparing mastectomy techniques
nipple sparing mastectomies
Long term outcome
• Post skin sparing mastectomy the recurrence risk is less than 1%
• the actual incidence of these patients developing breast cancer post mastectomy cannot be accurately quantified
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• Chasing the nirvana of the perfect breast reconstruction results in conflict between surgical oncology principles and aesthetically pleasing better functioning reconstructed breasts
Radiation therapy
Part of local and part of systemic treatment
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BREAST INDICATIONS
breast conservation surgery
intra‐operative radiation should be part of a trial
Margins post mastectomy
Any person who has a locally advanced breast cancer (tumour bigger than 5cm)
REGIONAL (NODAL) INDICATIONS
if 3 or more positive nodes (1‐3 nodes positive conflicting data)
SYSTEMIC INDICATIONS
Metastatic disease control (brain) (bone) (spinal compression)
Chemotherapy rules •
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Most pre‐menopausal women
All tumours > 1.0cm in women fit for chemotherapy
1+ lymph node positive disease
Hormone receptor negative tumours
Tumours with aggressive biology (lymph / vascular invasion, poorly differentiated)
Her 2 positive breast cancers
Genetic Profiling of tumours
Primary chemotherapy
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gold standard for all patients with locally advanced breast cancer
does facilitate cosmesis Form of biological warfare
Primary chemotherapy Rules
• Primary chemotherapy is the gold standard for all patients with locally advanced breast cancer
• Primary chemotherapy can be used to facilitate cosmesis and make breast conservation feasible in some patients
• Systemic chemotherapy can improve survival in patients with metastatic breast cancer • Systemic chemotherapy produces durable remission in some patients with metastatic breast cancer
There is most definitely a place for surgery in patients with advanced breast cancer, the question is when
• Chemotherapy upfront, followed by surgery (timed when appropriate, see below), although the ship is still going to sink, this may be a more dignified exit approach and akin to the band playing while a few brave souls continue dancing….and who knows some may reach a life boat
The effect of Advanced breast cancer on quality of life
• The physical issues of pain, odour and loss of function must be carefully considered when deciding on treating or withholding treatment in these women
• Locally advanced central tumours, which have had a good response to primary chemotherapy, are not contraindications for central breast excisions and reconstruction • Chemotherapy today is more individualised and less recipe as more combinations of drugs become available
Target therapies
• Amplification of the Her2/neu is associated with increased aggressiveness of breast cancers. Trastuzumab should be utilised in these patients
• Availability of more target therapies, have resulted in better patient outcomes
• As access to target therapies can be expensive, it behoves all physicians involved in the treatment of breast cancer to be aware of trials available to their patients
Endocrine therapy
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All patients with hormone receptor –positive tumours reduces the risk of recurrence and improves overall survival
Not for ER/PR negative tumours Treatment started once chemotherapy is completed Endocrine Therapy
• Pre‐menopausal women : Tamoxifen
• Post menopausal women Either Tamoxifen or Aromatase inhibitors
• Minimum of 5 years
• Beware bleeding on Tam
• Beware if you don’t know if the patient is menopausal (TAH) (contraceptives)
Problems with SERMS
Patient Follow‐up
• History taking, eliciting symptoms and physical examination every 3‐6 months for 3 years , then 6‐
12months for 3 years , then annually with attention paid to long term side‐effects (osteoporosis)
• Ipsilateral and contralateral radiology every year
• Not routinely recommended for asymptomatic patients: blood counts; chemistry, chest Xray, bone scan, liver ultrasound, chest scans of chest or abdomen • Any tumour marker such as CA 153, CEA are not recommended
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like a rainbow…
A few driven clinicians across the country, who although are as unique as each colour
, • strive daily towards the pot of gold of true excellent patient care • ensuring an integrated, education orientated, multidisciplinary approach; with cost effective service delivery and high quality patient care