Breast Cancer Treatment In The Breast Cancer Treatment In The 21st Century21st Century21st Century21st Century

Strategies for maintaining health and well being for Strategies for maintaining health and well being for decades of survivaldecades of survivaldecades of survivaldecades of survival

NYSPA Symposium NYSPA Symposium y py pMay 9, 2011May 9, 2011

h C C h C Sh C C h C SAnthony C. Cahan, M.D., F.A.C.S.Anthony C. Cahan, M.D., F.A.C.S.Chief, Breast Surgery DivisionChief, Breast Surgery Division

Northern Westchester HospitalNorthern Westchester HospitalNorthern Westchester Hospital,Northern Westchester Hospital,Mt Kisco, NYMt Kisco, NY

Question:Question:Question:Question:What do these 4 patients have in common?What do these 4 patients have in common?

Answer:Answer:Answer:Answer:They have all had mastectomies.They have all had mastectomies.

1974 1984

1994 2004

Question:Question:Question:Question:How do they differ?How do they differ?

Answer:Answer:Answer:Answer:In their chances of survival.In their chances of survival.

The Quiet The Quiet RevolutionRevolutionThe Quiet The Quiet RevolutionRevolution

1974 200476% 5 Year Survival 90% 5 Year Survival

Trends In 5 Year Breast Cancer Trends In 5 Year Breast Cancer d 5 a a ad 5 a a aSurvival Rates In The U.S.Survival Rates In The U.S.

90%

95%

80%

85%

90%

5 YearSurvival

70%

75%

80%

65%

70%

1975-77 1984-86 1996-2002

Factors Affecting Breast Cancer SurvivalFactors Affecting Breast Cancer SurvivalFactors Affecting Breast Cancer Survival Factors Affecting Breast Cancer Survival Duration and QualityDuration and Quality

Early DiagnosisEarly DiagnosisMammographyMammographySonographySonographyMRIMRI

f ( )f ( )Breast Specific Gamma Imaging (BSGI)Breast Specific Gamma Imaging (BSGI)

Risk Assesment and IdentificationRisk Assesment and IdentificationBRCA G t tBRCA G t tBRCA Gene testBRCA Gene testTissue markers of RiskTissue markers of Risk

Atypical hyperplasia lobular neoplasiaAtypical hyperplasia lobular neoplasiaAtypical hyperplasia, lobular neoplasiaAtypical hyperplasia, lobular neoplasia

Factors Affecting To Breast Cancer Factors Affecting To Breast Cancer a o g o a aa o g o a aSurvival Duration and QualitySurvival Duration and Quality

Improved Pathology AssessmentImproved Pathology AssessmentBetter educationBetter educationBetter educationBetter educationTumor MarkersTumor Markers

Estrogen/Progesterone Receptors, Her 2 Neu Estrogen/Progesterone Receptors, Her 2 Neu st oge / ogeste o e ecepto s, e eust oge / ogeste o e ecepto s, e euOncogene ExpressionOncogene Expression

Genetic ProfilingGenetic ProfilingOncotype Dx, MammaprintOncotype Dx, Mammaprint

Factors Affecting Breast Cancer Factors Affecting Breast Cancer a o g a aa o g a aSurvival Duration and QualitySurvival Duration and Quality

Locoregional Therapy: Surgery and Locoregional Therapy: Surgery and IrradiationIrradiation

Customized to individualCustomized to individualMastectomy vs. LumpectomyMastectomy vs. LumpectomyR t tiR t tiReconstructionReconstructionIntraoperative Radiation Therapy (IORT)Intraoperative Radiation Therapy (IORT)

Less morbidityLess morbidityLess morbidityLess morbiditySentinel lymph node biopsySentinel lymph node biopsySkin/nipple preserving mastectomySkin/nipple preserving mastectomy

Factors Affecting Breast Cancer Factors Affecting Breast Cancer a o g a aa o g a aSurvival Duration and QualitySurvival Duration and Quality

Systemic therapy: Systemic therapy: Treating the cells that Treating the cells that might have escaped.might have escaped.g pg p

ChemotherapyChemotherapypypyTaxol, Adriamycin, Cytoxan, HerceptinTaxol, Adriamycin, Cytoxan, Herceptin

HormonalHormonalTamoxifen, anastrozole, letrozole, exemestaneTamoxifen, anastrozole, letrozole, exemestane

Factors Affecting Breast Cancer Factors Affecting Breast Cancer a o g a aa o g a aSurvival Duration and QualitySurvival Duration and Quality

Post Treatment Management:Post Treatment Management:MedicalMedicalMedicalMedical

Weight, BP, cholesterol, blood sugar, bone density, Weight, BP, cholesterol, blood sugar, bone density, bone /muscle pain, neuropathybone /muscle pain, neuropathy

PsychosocialPsychosocialExercise, menopause, depression, cognitive Exercise, menopause, depression, cognitive changes, sex, divorce, deathchanges, sex, divorce, death

The Breast Cancer Treatment TeamThe Breast Cancer Treatment Team19741974

SurgeonSurgeonPathologistPathologistPathologistPathologistMedical Oncologist (maybe)Medical Oncologist (maybe)R di ti O l i t ( b )R di ti O l i t ( b )Radiation Oncologist (maybe)Radiation Oncologist (maybe)

The Breast Cancer Treatment TeamThe Breast Cancer Treatment TeamThe Breast Cancer Treatment TeamThe Breast Cancer Treatment Team20112011

Aesthetic OncologistsAesthetic OncologistsOncologic SurgeonsOncologic SurgeonsPlastic and Reconstructive SurgeonsPlastic and Reconstructive SurgeonsPlastic and Reconstructive SurgeonsPlastic and Reconstructive Surgeons

RadiologistsRadiologistsDiagnosticDiagnosticDiagnosticDiagnosticInterventionalInterventional

PathologistsPathologistsMedical OncologistsMedical OncologistsRadiation OncologistsRadiation OncologistsCancer GeneticistCancer Geneticist

The Breast Cancer Treatment TeamThe Breast Cancer Treatment Teama a a aa a a a20112011 (continued)(continued)

Primary Care PhysicianPrimary Care PhysicianEndocrinologistEndocrinologistGynecologistGynecologistComplementary Care SpecialistComplementary Care SpecialistAnesthesiologistsAnesthesiologistsNursingNursing

ORORORORFloorFloor

Physical TherapistsPhysical TherapistsPhysical TherapistsPhysical Therapists

Breast Cancer Treatment InBreast Cancer Treatment InTh 21 t C tTh 21 t C tThe 21st CenturyThe 21st Century

The Quiet The Quiet RevolutionRevolution::The Quiet The Quiet RevolutionRevolution::

Dramatic changes in the surgical Dramatic changes in the surgical management of breast cancermanagement of breast cancer

“Doing less is more”“Doing less is more”

LymphedemaLymphedema

Lymphatic Mapping and Sentinel Node BiopsyLymphatic Mapping and Sentinel Node Biopsy

The “sentinel” node is the firstnode to receive lymphaticdrainage from a primary tumordrainage from a primary tumor.Thus, it is the first node to whicha tumor will metastasize.

If the sentinel node is negativefor metastatic disease, theremaining nodes in thelymphatic basin are also likely tobe negative.g

Sentinel Lymph Node BiopsySentinel Lymph Node BiopsySentinel Lymph Node BiopsySentinel Lymph Node BiopsyRadioactive Tracer InjectionRadioactive Tracer Injection

Sentinel Lymph Node BiopsySentinel Lymph Node BiopsySentinel Lymph Node BiopsySentinel Lymph Node BiopsyPrePre--Op LymphoscintigramOp Lymphoscintigram

Sentinel Lymph Node BiopsySentinel Lymph Node BiopsySentinel Lymph Node BiopsySentinel Lymph Node BiopsySentinel Lymph Node RemovedSentinel Lymph Node Removed

Sentinel L mph Node BiopsSentinel L mph Node BiopsSentinel Lymph Node BiopsySentinel Lymph Node Biopsy

Incidence of LymphedemaIncidence of LymphedemaAxillary Dissection: 20%Axillary Dissection: 20%Axillary Dissection: 20%Axillary Dissection: 20%Sentinel Lymph Node Biopsy: <2%Sentinel Lymph Node Biopsy: <2%

Nerve injury significantly reducedNerve injury significantly reducedNerve injury significantly reducedNerve injury significantly reducedSame or more clinical information Same or more clinical information obtainedobtainedobtainedobtained

Breast Cancer Treatment InBreast Cancer Treatment InTh 21 t C tTh 21 t C tThe 21st CenturyThe 21st Century

Aesthetic OncologyAesthetic Oncology

The preservation or enhancement of body The preservation or enhancement of body form following cancer surgeryform following cancer surgeryform following cancer surgeryform following cancer surgery

Breast Cancer Treatment InBreast Cancer Treatment InTh 21 t C tTh 21 t C tThe 21st CenturyThe 21st Century

Aesthetic Oncological Procedures For Aesthetic Oncological Procedures For Breast CancerBreast Cancer

Minimal scar lumpectomyMinimal scar lumpectomyLumpectomy with oncoplastic reconstructionLumpectomy with oncoplastic reconstructionLumpectomy with oncoplastic reconstructionLumpectomy with oncoplastic reconstructionSkin sparing mastectomy with Immediate Skin sparing mastectomy with Immediate ReconstructionReconstructioneco st uct oeco st uct oNipple Sparing Mastectomy with Immediate Nipple Sparing Mastectomy with Immediate ReconstructionReconstruction

Breast Cancer Treatment InBreast Cancer Treatment Ina a aa a aThe 21st CenturyThe 21st Century

Minimal scar lumpectomyMinimal scar lumpectomy

Breast Cancer Treatment InBreast Cancer Treatment Ina a aa a aThe 21st CenturyThe 21st Century

Lumpectomy with oncoplastic Lumpectomy with oncoplastic reconstructionreconstruction

Breast Cancer Treatment InBreast Cancer Treatment InTh 21 t C tTh 21 t C tThe 21st CenturyThe 21st Century

Skin Sparing MastectomySkin Sparing MastectomyIncision is within areolar diameterIncision is within areolar diameterIncision is within areolar diameterIncision is within areolar diameter

Skin NOT involved or close to cancerSkin NOT involved or close to cancerS O o ed o c ose to ca ceS O o ed o c ose to ca cePatient is not candidate for lumpectomy or desires Patient is not candidate for lumpectomy or desires mastectomymastectomy

Breast Cancer Treatment InBreast Cancer Treatment Ina a aa a aThe 21st CenturyThe 21st Century

Nipple Sparing Mastectomy with Nipple Sparing Mastectomy with Immediate ReconstructionImmediate Reconstruction

Performed in prophylactic settingPerformed in prophylactic settingBRCA mutationBRCA mutationHigh risk breast secondary to atypiaHigh risk breast secondary to atypiaPatient desirePatient desire

Controversial in patients with breast cancerControversial in patients with breast cancer

Breast Cancer Treatment InBreast Cancer Treatment Ina a aa a aThe 21st CenturyThe 21st Century

After treatment for breast cancer, what After treatment for breast cancer, what next?next?

Remember the whole personRemember the whole personExerciseExerciseWeight managementWeight managementVitamins/SupplementsVitamins/Supplements

Calcium and Vitamin DCalcium and Vitamin D

Hormones?Hormones?

Breast Cancer Treatment InBreast Cancer Treatment Ina a aa a aThe 21st CenturyThe 21st Century

Conclusion:Conclusion:Increasingly, women diagnosed with breast cancer will live Increasingly, women diagnosed with breast cancer will live

long lives following their diagnosislong lives following their diagnosislong lives following their diagnosis.long lives following their diagnosis.Preserving a sense of well being and body image following Preserving a sense of well being and body image following

treatment is more important than ever.treatment is more important than ever.To achieve this, careful consideration of the individual’s To achieve this, careful consideration of the individual’s

needs, selective use of chemo/hormonal therapy and needs, selective use of chemo/hormonal therapy and adherence to aesthetic oncologic techniques are adherence to aesthetic oncologic techniques are essential.essential.

Overall health should never be forgotten. Overall health should never be forgotten.