Breast Cancer Adjuvant therapy Update

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