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
Breast Cancer Treatment:
A Multidisciplinary Team Approach
•Radiology
•Pathology
•Surgery
•Radiation
Oncology
•Medical
Oncology
Fighting the Crab – Kiev, Ukraine
Personalized Cancer Medicine
New Strategies in Treating Breast Cancer:
Better Targeting
Individualized Approaches
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
Diagnosing the Cancer: UltrasoundGuided Breast Biopsy
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
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
Defining the Cancer: Radiology
• Radiologic imaging can help determine the
location and spread of the cancer
– Local extent
– Regional lymph nodes
– Distant spread (metastases)
Evaluating Extent of Local Disease:
Breast Cancer
Mammogram: Area of abnormality extends over 60
mm
Staging for Distant Disease: Breast
Cancer
Patient A
Bone Scan
Multiple
bone
metastases
The most common sites of distant disease in breast
cancer are the bones, liver and lungs
Breast Cancer Surgery
Sometimes “less”
surgery is better
•Mastectomy vs.
lumpectomy
•Lymph node
dissection vs. sentinel
lymph node biopsy
Lumpectomy: Wire Localization of NonPalpable, Imaging-Detected Breast Cancers
Lumpectomy Margin Evaluation: Inking
the Tumor Specimen in the Operating
Room
Sentinel Lymph Node Biopsy
1. Inject around area
of tumor with blue
dye, radioactivity, or
both
sentinel node biopsy
requires substantial
technology,
resources, and
training
2. Track the
lymphatic drainage
of the tumor
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
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
Systemic Therapy for Breast Cancer
Endocrine Therapy
Chemotherapy
Biologically-targeted Therapy
New Strategies: Individualizing treatment
to the cancer and the patient
Identifying New Targets in the
Treatment of Breast Cancer
Metastasis
Inhibitors
AntiAngiogenesis
EGFR
Inhibitors
HER-2
Inhibitors
mTOR
Inhibitors
IGF-R
Inhibitors
Src
Inhibitors
MUC-1
Antibodies
Farnesyl
Transferase
MEK
HIF
Cell Cycle Inhibitors
Inhibitors
Inhibitors
Inhibitors
Aurora Kinase
HSP90
Inhibitors
Inhibitors
Raf
Pro-apoptotic
Inhibitors
Drugs
Proteosome
Mdm2
Kinesins
Inhibitors
Inhibitors
HDAC
TubulinInhibitors
interacting
Death
Agents
Receptors
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