•Myriad Speaker’s Bureau (not

today)

o I have given lectures and met with health

care providers in other states (Missouri,

Minnesota, Nebraska, Colorado, Oklahoma)

to educate physicians about the risk factors

for BRCA.

oThis is NOT sponsored by Myriad and

should represent an unbiased presentation

of regional testing data (although

incomplete- not all data was released).

Disclosure

• Presentation of breast cancer

• Changes in treatmento surgical approach to breast cancer.....

o chemotherapy indications

o oncoplastic techniques

• Preventing cancer o “previvors”

o Therese Cusick, MD FACS

Breast Cancer Update

Obvious vs.

Subtle

many different presentations....

PAGET’S DISEASE

Scaly nipple

Left

MLO

How a cancer

SHOULD

present...

• 0- Incomplete

• 1- Without lesion

• 2- Benign lesion

• 3- Lesion of low suspicion

• 4- Moderately suspicious lesion

• 5- Highly suspicious lesion

BI-RADS

Left

MLO

Breast MR

• Used to prove uni-focal disease

• Lobular breast cancero Multifocal

o Increased incidence of bilaterality

o Difficult to visualize with mammography

o Vague physical exam

• Dense Mammogramso Young patients

o Occasionally older pts with dense

mammos

(look at cancer on the mammogram)

Dense breast

Solitary mass with no other

abnormality

Diagnosis of Breast

Cancer-2010• Breast Cancer diagnosis should be

made by a core bx, NOT OPEN BX IN

OR!

• Allows for pre-planning, oncoplastic

techniques, improved SLN

• Does everyone need a core pre-

operatively?o If one suspects cancer, yes (unless

advanced age)

o If pt desires excision of a lesion thought

highly likely to be benign, no

CHEMOTHERAPY

Changes in

treatment…• Chemotherapy decisions are no

longer based on size of tumor and

lymph node status alone…

• Individualized to the patient!

• Tumor BIOLOGY…

Oncotype DX™ 21-Gene Recurrence Score (RS) Assay

PROLIFERATION

Ki-67

STK15

Survivin

Cyclin B1

MYBL2

ESTROGEN

ER

PR

Bcl2

SCUBE2

INVASION

Stromelysin 3

Cathepsin L2

HER2

GRB7

HER2

BAG1GSTM1

REFERENCE

Beta-actin

GAPDH

RPLPO

GUS

TFRC

CD68

16 Cancer and 5 Reference Genes From 3 Studies

Category RS (0-100)

Low risk RS <18

Int risk RS ≥18 and <31

High risk RS ≥31

RS = + 0.47 x HER2 Group Score

- 0.34 x ER Group Score

+ 1.04 x Proliferation Group Score

+ 0.10 x Invasion Group Score

+ 0.05 x CD68

- 0.08 x GSTM1

- 0.07 x BAG1

Pre-Operative

Chemotherapy• Neo-adjuvant Chemotherapy

o Inflammatory Breast Cancer

-Chemo, mastectomy, radiation

o Large tumors in an attempt to close with

mastectomy

o Large tumors in an attempt to proceed with

breast conservation

-Note that not all cancers shrink concentrically

•Smaller vs. the “swiss cheese” effect

-Must place a tumor marker!!!

o Node Positive Patients

-Enlarged nodes noted at time of dx, FNA+

o Suspected BRCA

-Allows additional time for testing to return

Improvements

• Radical Mastectomy

• Modified Radical Mastectomy

• Lumpectomy and axillary node

dissection

• SENTINEL LYMPH NODEo Mastectomy or lumpectomy

• Oncoplastic surgeryo Lumpectomy with local tissue rearrangement

o Reduction lumpectomy

o Skin and nipple sparing mastectomies

Is lumpectomy a step up from mastectomy?left= mastectomy and reconstruction Right= bad lumpectomy deformity

London-Royal College

of Surgeons

• A woman had to “prove herself

worthy” of reconstruction by living 5

years without a breast (due to the

shortage of plastic surgeons in

England).

Oncoplastics

• Combining plastic surgery and breast

cancer surgery

• Preplanning required

• Team approach with plastic surgeon

• Some cases-cancer surgeon only

Cancer vs. Cosmesis

Nipple Sparing

Peau de orange

Previous Incision

Nipple SparingNipple

Sparing

Mastectomy

Specimen

Nipple

Before

mastectomy

(left)

After

Mastectomy

(right)

Mastectomy with reconstruction

Post-Mastectomy

Radiation• Classic Indications

o Tumor larger than 5 cm

o 4 or more +LN

o Involved margins/Chest wall

o Inflammatory Breast Cancer

• Possible Indicationso 1-3 + nodes in pre-monepausal pt

Post-Mastectomy

Radiation

• Attempt to predict preoperatively who

will need post-mastectomy radiationo Not ideal to radiate muscle flaps

-TRAM flaps

-Latissimus flaps

-These flaps may be used to reconstruct AFTER

radiation

o OK to radiate tissue expanders

-Deflate

-Place implant (5th generation) vs. flap

2006 ASCO Recommendations

(Von Wald)

“As part of education and informed consent prior to cancer

therapy, oncologists should address the possibility of infertility

with patients treated during their reproductive years and be

prepared to discuss possible fertility preservation options or

refer appropriate and interested patients to reproductive

specialists. Clinician judgment should be employed in the

timing of raising this issue, but discussion at the earliest

possible opportunity is encouraged. Sperm and embryo

cryopreservation are considered standard practice and widely

available; other available fertility preservation methods should

be considered investigational and be performed in centers

with the necessary expertise.Lee SJ, et al. J Clin Oncol 2006;24(18):1-16

BRCA

• >80% lifetime risk of breast cancer

• Up to 44% risk of ovarian cancer

• 64% chance of second breast cancer

• Red flagso Breast cancer <age 50

o Breast and ovarian cancer

o Male breast cancer

Young

◦ Age < 45

Young and Multiple

◦ Age <50

◦ At least 2 cancers (young breast,

ovarian)

Multiple

◦ 3 total cancers regardless of age

Combination of breast and ovarian

(male breast cancer counts as 2)

Testing Criteria 1,2,3

Bilateral mastectomies with

reconstruction vs.

Annual MRI alternating with annual

mammography (q 6 months)

Second breast cancer

◦ Ipsilateral vs. contralateral breast

◦ Tissue is radiated….

Prevent second breast cancers in our pts

Prevent ovarian cancers in our pts

Select appropriate surgeries for our

newly diagnosed pts

Identify families so we can prevent these

cancers in their family members

Surgeon Testing

If you believe that 20% of breast cancer

patients are appropriate for testing, we are

now improving our numbers to come closer

to that estimate.

Those states that exceed the 20% rule, are

likely capturing past cancer patients that

were not previously tested.

Have we truly only identified 10% of BRCA

carriers?

Average #

Cancers/Yr

Average #

BRCA/Yr

% affected

tested

Missouri 4824 546 11.31%

Oklahoma 2960 149 5.03%

Arkansas 2180 126 5.77%

Kansas 1890 304 16.08%

Nebraska 1224 187 15.27%

2003-2008

Recent tests by specialty

(5 state area)

81

GENETICIST, MD

KANSAS

2008 BREAST CANCER

%TESTED

46 year old patient was diagnosed with

breast cancer at the age of 33.

◦ Opted for bilateral mastectomies and

reconstruction.

◦ Family hx

Maternal great aunt with ovarian CA

Maternal great grandmother with breast

cancer

◦ Pt recently diagnosed with Stage 3

ovarian cancer

◦ Criterion for testing?

29 year old, newly diagnosed 3 cm

breast cancer

◦ Neoadjuvant chemotherapy?

◦ Lumpectomy and radiation?

◦ Mastectomy and reconstruction?

◦ Bilateral mastectomies with

reconstruction?

◦ Oophorectomy?

ovaries?

Timing of oophorectomy

important if placing

mesh....

www.facingourrisk.org

www.bebrightpink.org

Thank you! QUESTIONS?