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New Treatments for Early Breast Cancer

There were about 186,000 new cases of breast cancer in the year 2000, it is the second leading cause of cancer death in women only superseded by lung cancer. There is an increased incidence probably because of the increased use of screening mammography, one in 10 women who live to the age of 80 will get breast cancer, not 1 in 10 women in this room, but 1 in 10 women that are able to live to the age of 80. We need to remember that 1% of all breast cancers do occur in men. Risk factors are well known.

I am going to briefly go through the general management of three types of breast cancer because they are all unique in how to be managed. The first is lobular carcinoma in situ, then ductal carcinoma in situ and then invasive cancer. Lobular carcinoma in situ is classically defined as abnormal cells in the lobules and someone argued that this is really not a cancer at all. We would consider this to be sort of a risky breast. It makes up about one-third of all in situ lesions, it classically is more common in premenopausal women, it is an incidental finding, the mammogram is normal, and lobular carcinoma in situ is found when a biopsy is done for another reason, 40 to 80% of LCIS is multicentric, meaning if you biopsied the rest of the breast, you would find LCIS in about 40 to 80% of women, and 20 to 70% of patientís itís bilateral. In the old days they

Bilateral mastectomy, not unilateral but bilateral mastectomy used to be a very common procedure for LCIS because it treats both breasts, but this is an extreme procedure for a noninvasive, non life threatening condition of the breast, so bilateral mastectomy is usually reserved for women with either very high levels of anxiety.

Ductal carcinoma in situ is obviously enough abnormal cells in the ducts. This is a little different than lobular carcinoma in situ in the way that it presents and in itís management. The incidence of ductal carcinoma in situ is dramatically rising, about 10 years ago, it was about 2% of cancers that were diagnosed in women and many of those were palpable. Because of screening mammography, picking up these little tiny microcalcifications, the incidence of DCIS has risen to about 20 to 30% of all cancers and will probably continue to rise.

The most common treatment is lumpectomy or removal of the ductal carcinoma in situ with negative margins followed by radiation therapy and then again, one might have a discussion about tamoxifen. Lumpectomy and radiation therapy was first used for invasive disease and it wasnít later until we started using it for ductal carcinoma in situ. The control in the breast is about 80 to 92%, depending on patient selection and the carefulness of the physician in determining who is a candidate for breast preservation. Survival for ductal carcinoma in situ is 96 to 100%, this is a highly curable disease. Follow-up of these patientís is about 10 years and the benefits of tamoxifen will be discussed in a moment. This is just a graft to show four series of patientís this is a local control with excision plus radiation therapy and then this is the ultimate survival, so you can see that survival is excellent when a lumpectomy and radiation therapy are used. In the NSABP 24 trial, women were randomized to either receive placebo.

The real debate is, do all women need radiation therapy? Even though I am a radiation oncologist, sometimes I say probably this patientís wonít benefit. There is a certain morbidity to radiation, itís very expensive, one must question whether small low grade tumors, especially if you are considering adding tamoxifen need to have radiation therapy for improved local control. This is the kind of ductal carcinoma in situ I am talking about. I had to circle in red because you can barely see it. Itís a 3 mm low grade ductal carcinoma in situ, excised with 2 cm of normal margin. Does that patient really need radiation therapy?

Infiltrating ductal carcinoma is treated much like ductal carcinoma in situ with a few exceptions. You again start with bilateral mastectomy, biopsy, most of the time a post mastectomy mammogram, postbiopsy mammogram is indicated. A patient is then treated by either a modified radical mastectomy which includes dissection and chest wall radiation therapy is becoming increasingly used for premenopausal women based on the risk factors at the time of mastectomy. The vast majority of patientís are treated with breast preservation in which the axillary nodes.

There are several contraindications to breast preservation so you can judge when a woman walks in your office, may she be a candidate for breast preservation or not. If you have a large tumor, usually greater than 5 cm, most of the time they cannot be preserved. There are some considerations for neo-adjuvant chemotherapy but the vast majority of women would be best served by a mastectomy. If you have two palpable lesions in separate quadrants of the breast, usually they are not a candidate for breast preservation.

This is a mammogram of a woman that should not have breast preservations. I think the calcifications that you see are pretty obvious from the back of the room and these all indicate very extensive infiltrating and intraductal carcinoma, and this patient would be best served by a mastectomy. There are some relative contraindications to breast preservation. If a patient has a history of collagen vascular disease, especially lupus, their skin can have an extreme reaction.

This is a classic mammogram of a patient who is an excellent candidate for breast preservation. She has a small mass in the upper portion of her breast, very well defined, the rest of the breast is relatively fatty with no other lesions noted. The lesion is excised with needle localization and you can see the spiculations of the mass with a margin of normal breast tissue around it..

The complications of radiation are exceptionally rare, pneumonitis can occur, that happens in about 1 in 1000 women, rib fracture can occur years after the treatment is completed from osteoporosis, soft tissue necrosis is extremely rare and second malignancies are only really an issue in a very very young patient. This is what radiation pneumonitis looks like. This is a CAT scan of a patient who was treated to the left supraclavicular region, you can see the lung is clear here, but there is considerable scarring and fibrosis of this part of the radiated lung.

It has been my experience that women rarely go back to self breast exam after a diagnosis of malignancy for a whole variety of reasons, so itís really important for the physician to take the time to do a careful breast exam. Routine imaging and blood work is not needed.

I would love it if in five years I wouldnít have to stand up here anymore. We are always looking for the golden eggs that will allow us to prevent breast cancer once and for all. So I thought I would spend the last minute talking about some of the studies that have been done which are leading us in that direction. The NSABP 1 tried to prevent breast cancer in high risk women and they chose tamoxifen which was well defined for early breast cancer versus placebo. This was a huge study, received a lot of national attention, and basically these are the results. If you look at all tumors comparing tamoxifen in the light versus placebo in the orange.