julie r. gralow, m.d. director, breast medical oncology, seattle cancer care alliance
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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. - PowerPoint PPT PresentationTRANSCRIPT
Julie R. Gralow, M.D.Julie R. Gralow, M.D.Director, Breast Medical Oncology, Seattle Cancer Care AllianceDirector, Breast Medical Oncology, Seattle Cancer Care Alliance
Professor, Medical Oncology, University of Washington School of Professor, Medical Oncology, University of Washington School of MedicineMedicine
Member, Clinical Division, Fred Hutchinson Cancer Research CenterMember, Clinical Division, Fred Hutchinson Cancer Research Center
Treatment Overview: The Treatment Overview: The Multidisciplinary TeamMultidisciplinary Team
Breast Cancer Treatment: Breast Cancer Treatment: A Multidisciplinary Team ApproachA Multidisciplinary Team Approach
•RadiologyRadiology
•PathologyPathology
•SurgerySurgery
•Radiation Radiation OncologyOncology
•Medical Medical OncologyOncology
Fighting the Crab – Kiev, UkraineFighting the Crab – Kiev, Ukraine
Personalized Cancer MedicinePersonalized Cancer Medicine
New Strategies in Treating Breast Cancer:New Strategies in Treating Breast Cancer: Better TargetingBetter Targeting
Individualized ApproachesIndividualized Approaches
Cancer Treatment: Defining the Cancer Treatment: Defining the CancerCancer
• The first step in designing the treatment The first step in designing the treatment plan is carefully defining the cancerplan is carefully defining the cancer–Clinical examinationClinical examination–Radiology testsRadiology tests–Pathology testsPathology tests–Blood testsBlood tests
Diagnosing the Cancer: Ultrasound-Diagnosing the Cancer: Ultrasound-Guided Breast BiopsyGuided Breast Biopsy
Defining the Cancer: PathologyDefining the Cancer: Pathology
• Treatment recommendations are aided with Treatment recommendations are aided with the help of pathologic factorsthe help of pathologic factors–Prognostic factorsPrognostic factors: aid in estimating : aid in estimating
likelihood of cancer recurrence and deathlikelihood of cancer recurrence and death–Predictive factorsPredictive factors: predict likelihood of : predict likelihood of
response to a given therapyresponse to a given therapy
The First Step in Making a Treatment Plan The First Step in Making a Treatment Plan for Breast Cancer:for Breast Cancer: Defining the CancerDefining the Cancer
• StageStage– Tumor sizeTumor size– Lymph node statusLymph node status–Metastatic sitesMetastatic sites
• GradeGrade• Surgical marginsSurgical margins• Tumor expression of genes and Tumor expression of genes and
proteinsproteins– Estrogen receptor (ER)Estrogen receptor (ER)– Progesterone receptor (PR)Progesterone receptor (PR)– HER-2HER-2
Estrogen ReceptorEstrogen Receptor
Invasive Breast CancerInvasive Breast Cancer
HER-2HER-2
Defining the Cancer: RadiologyDefining the Cancer: Radiology
• Radiologic imaging can help determine the Radiologic imaging can help determine the location and spread of the cancerlocation and spread of the cancer– Local extentLocal extent–Regional lymph nodesRegional lymph nodes–Distant spread (metastases)Distant spread (metastases)
Mammogram: Area of abnormality extends over 60 Mammogram: Area of abnormality extends over 60 mmmm
Evaluating Extent of Local Disease: Evaluating Extent of Local Disease: Breast CancerBreast Cancer
Bone Scan Bone Scan
Staging for Distant Disease: Breast Staging for Distant Disease: Breast CancerCancer
Multiple Multiple bone bone
metastasesmetastases
Patient APatient A
The most common sites of distant disease in breast The most common sites of distant disease in breast cancer are the bones, liver and lungscancer are the bones, liver and lungs
Breast Cancer SurgeryBreast Cancer SurgerySometimes “less” Sometimes “less” surgery is bettersurgery is better
•Mastectomy vs. Mastectomy vs. lumpectomylumpectomy
•Lymph node Lymph node dissection vs. sentinel dissection vs. sentinel lymph node biopsylymph node biopsy
Lumpectomy: Wire Localization of Non-Lumpectomy: Wire Localization of Non-Palpable, Imaging-Detected Breast CancersPalpable, Imaging-Detected Breast Cancers
Lumpectomy Margin Evaluation: Inking Lumpectomy Margin Evaluation: Inking the Tumor Specimen in the Operating the Tumor Specimen in the Operating
Room Room
Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy
1. Inject around area 1. Inject around area of tumor with blue of tumor with blue dye, radioactivity, or dye, radioactivity, or bothboth
2. Track the 2. Track the lymphatic drainage lymphatic drainage of the tumorof the tumor
sentinel node biopsy sentinel node biopsy requires substantial requires substantial
technology, technology, resources, and resources, and
trainingtraining
Breast Cancer Radiation Breast Cancer Radiation TherapyTherapy
• The future: is “less” radiation The future: is “less” radiation sometimes better?sometimes better?
–Whole breast versus Whole breast versus partial breast radiation partial breast radiation (brachytherapy)(brachytherapy)
– Hypofractionation (shorter Hypofractionation (shorter course)course)
– 3D conformal radiation 3D conformal radiation planningplanning
Indications for Radiation Indications for Radiation Therapy After MastectomyTherapy After Mastectomy
• Tumor size > 5 cmTumor size > 5 cm• Inflammatory features or skin Inflammatory features or skin
involvementinvolvement• Multiple positive lymph nodesMultiple positive lymph nodes• Extracapsular lymph node extensionExtracapsular lymph node extension• Positive surgical marginsPositive surgical margins
Systemic Therapy for Breast CancerSystemic Therapy for Breast Cancer
Endocrine TherapyEndocrine TherapyChemotherapyChemotherapy
Biologically-targeted TherapyBiologically-targeted Therapy
New Strategies: Individualizing treatment New Strategies: Individualizing treatment to the cancer and the patientto the cancer and the patient
Identifying New Targets in the Identifying New Targets in the Treatment of Breast CancerTreatment of Breast Cancer
Death Death ReceptorsReceptors
Tubulin-Tubulin-interacting interacting
AgentsAgents
HDAC HDAC InhibitorsInhibitors
Metastasis Metastasis InhibitorsInhibitors
Anti-Anti-AngiogenesisAngiogenesis
HER-2 HER-2 InhibitorsInhibitors IGF-R IGF-R
InhibitorsInhibitors MUC-1 MUC-1 AntibodiesAntibodies
Proteosome Proteosome InhibitorsInhibitors
mTOR mTOR InhibitorsInhibitors Farnesyl Farnesyl
Transferase Transferase InhibitorsInhibitors
Mdm2 Mdm2 InhibitorsInhibitors
Pro-apoptotic Pro-apoptotic DrugsDrugs
KinesinsKinesins
Aurora Kinase Aurora Kinase InhibitorsInhibitors
MEK MEK InhibitorsInhibitorsHIF HIF
InhibitorsInhibitors
Raf Raf InhibitorsInhibitors
EGFR EGFR InhibitorsInhibitors
HSP90 HSP90 InhibitorsInhibitors
Src Src InhibitorsInhibitors
Cell Cycle Cell Cycle InhibitorsInhibitors
Optimizing Health and Wellness After Optimizing Health and Wellness After Treatment of Breast Cancer: Treatment of Breast Cancer:
SurvivorshipSurvivorship
• Many breast cancer Many breast cancer patients can look patients can look forward to a long life forward to a long life after treatmentafter treatment
• Breast cancer patients Breast cancer patients and their health care and their health care team need to pay team need to pay attention to all aspects attention to all aspects of health and well-beingof health and well-being
Team Survivor NorthwestTeam Survivor Northwest