Breast Cancer Adjuvant therapyUpdate
Presentation to The Annual Current Therapy Seminar, Portsmouth, OH
Li-Fen Lien Chang, MD PhD Radiation Oncology Department
SOMC Cancer Center
10/23/2009
Paradigm Shift: RT Less is more?
• The importance of radiation therapy for breast cancer is well established (multiple phase III randomized trials and Level1 evidence)
• Without local regional control of cancer, one can not achieve a cure.
• As the systemic therapy become more effective, the local regional control become even more important.
Accelerated Partial Breast Irradiation (APBI)
Then Whole Breast Irradiation after lumpectomy:
standard of care for early stage breast cancer patient. It take 6 ½ weeks daily EBRT.
Now APBI (Accelerated Partial Breast Irradiation); 5
years of follow up data indicates same effectiveness and less side effect, less time consuming ( 5 days BID fractionation).
Patient selection is the key
Who is a candidate for APBI?
• Invasive Ductal Carcinoma• <3cm• Negative lymph nodes• Clear margin• The skin -balloon surface distance >7mm• >45 yo
MammoSite: Breast Brachytherapy
3-Dimensional rendering of applicator surface
CT Image of MammoSiteTissue Conformance
Skin Spacing
Balloon Diameter & Symmetry
Contura MLB (Multilumen Balloon) applicator
Contura is the newest generation of brachytherapy applicators which enable the radiation dose to target more of the breast tissue that is a concern while minimizing the radiation dose to healthy tissue. Suction ports allows removal of air or seroma.
Hormonal Therapy: for ER+, PR+ Then:
Tamoxifen for 5 yearsEvista achieve the same effectiveness
Now:Postmenopausal women
Aromatase inhibitor (AI) is better then Tamoxifen
Premenopausal womenTamoxifen
Who needs chemotherapy?
• Then– >1cm, positive lymph nodes, <50yo, high tumor grade,
high DNA S phase,
• Now– Oncotype DX:
• a 21-gene expression profile• Recurrent Score: Low risk, Intermediate risk
or high risk group– MammaPrint:
• a 70-gene expression profile
Oncotype DX Recurrent Score
Targeted Therapy: effective and low toxicity• Then:
no known specific target
• Now:– HER2/neu+: Trastuzumab (Herceptin), Lapatinib
(Tykerb)– VGEF: Bevacezumab (Avastin)– HER1:Gefitinib (Irressa)
Triple Negative Breast Cancer: ER/PR/Her2-• under the age of 40, • Black or Hispanic• more aggressive • Higher five years recurrence• Higher mortality rate• Basoloid cell • BRCA1/2 mutation • PARP (poly (ADP-ribose) polymerase)
inhibitor increase the chemotherapy effectiveness
Paradigm Shift for Breast Cancer Adjuvant Therapy •Tailored therapy:– Whole breast radiation APBI (Accelerated Partial
Breast Irradiation)
– Oncotype Dx Recurrent Score who to give chemotherapy
– ER/PR+ Postmanopausal women AIs (Aromatase Inhibitors) are better then Tamoxifen
– HER2/Neu+ woman Herceptin
– Triple negative (ER/PR/HER2-) Breast cancer PARP inhibitors improve out come
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