Diagnosing and Treating Adult Cancers and Associated Impairments (2021) / Chapter Skim
Currently Skimming:
5 Breast Cancer
5 Breast Cancer
Pages 107-154
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From page 107... ...
. Fortunately, only about 6% of patients have metastatic breast cancer at the time of their initial diagnosis (Howlader et al., 2020)
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for breast cancer from initial screening and diagnosis through breast cancer staging (including its major subtypes) to the treatment options for both local and metastatic disease.
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From page 109... ...
Metastasis to lymph nodes can be diagnosed either by a biopsy, such as a core needle biopsy or a fine-needle aspiration, which uses a smaller needle than a core biopsy, or by surgery. Once the biopsy tissue has been extracted, it is examined by pathologists who determine whether cancer is present and, if so, the type of breast cancer and the tumor grade and margins.
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, the spread to lymph nodes (N) , and metastasis to distant organs (M)
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From page 111... ...
TABLE 5-1 Anatomic Staging of Invasive, Nonmetastatic Breast Cancer Stage Detailed Stage TMN Stage I Stage IA • T1, N0, M0 Stage IB • T0, N1, M0 • T1, N1, M0 II Stage IIA • T0, N1, M0 • T1, N1, M0 • T2, N0, M0 Stage IIB • T2, N1, M0 • T3, N0, M0 III Stage IIIA • T0, N2, M0 • T1, N2, M0 • T2, N2, M0 • T3, N1, M0 • T3, N2, M0 Stage IIIB • T4, N0, M0 • T4, N1, M0 • T4, N2, M0 Stage IIIC • Any T, N3, M0 NOTE: M = presence or absence of distant metastasis; N = extent of regional lymph node spread; T = size or extent of the primary tumor (see Chapter 4 for more information on cancer staging)
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From page 112... ...
NOTES: BCS = breast‐conserving surgery; chemo = chemotherapy, including targeted therapy and immunotherapy; RT = radiation therapy. a A small number of these patients received chemotherapy.
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From page 113... ...
DCIS cells are not capable of metastasizing or spreading outside the breast to lymph nodes or other distant organs, so lymph node dissection is generally not needed. There is a low risk of DCIS becoming invasive, and therefore the current standard of care is to treat DCIS with BCS with or without radiation therapy or tamoxifen or else to treat it with a mastectomy in a manner similar to what is typical for invasive breast cancer.
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From page 114... ...
Additional adjuvant therapy ER-pos and/or PR-pos HER2-pos 5–10 years of adjuvant endocrine therapy • HER2-directed therapy Premenopausal at Postmenopausal • Patients with ER-pos diagnosis and/or PR-pos cancer Tamoxifen monotherapy; Aromatase inhibitor; should receive concurrent or ovarian-suppressing taxoxifen; or sequence of both adjuvant endocrine therapy medication plus tamoxifen or aromatase inhibitor FIGURE 5-3 Typical stage I to stage III invasive breast cancer care algorithm. NOTE: CT = computed tomography; ER = estrogen receptor; HER2 = human epidermal growth factor receptor 2; HR = hormone receptor; MRI = magnetic resonance imaging; PET = positron emission tomography; PR = progesterone receptor.
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From page 115... ...
The treatment of metastatic breast cancer, discussed after the treatment of localized breast cancer, focuses primarily on systemic therapy, although surgery and radiation are used in certain situations. Surgical Treatments Decisions about the surgical management of the primary breast tumor and the lymph nodes are made almost separately, depending on anatomic stage, biomarkers, and patient preferences.
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From page 116... ...
. Surgical Management of Axillary Nodes A metastasis of breast cancer to the axillary lymph nodes is determined by physical exam and imaging, commonly by ultrasound.
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In order to minimize the adverse effects from lymph node removal such as lymphedema, neuropathy, and seromas, surgeons may perform a sentinel lymph node dissection (SLND, or sentinel lymph node biopsy) to remove only the first few axillary lymph nodes draining a breast tumor; this is performed for early-stage clinically node-negative breast cancer.
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From page 118... ...
Although the rates of breast reconstruction after mastectomy have been increasing, only about 24% of U.S. patients with invasive breast cancer undergo reconstruction at the same time as their mastectomy (Kamali et al., 2019)
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, tumor biology based on receptor status, lymph node status, and patient age. In this section the indications for radiation therapy and fractionation schedules for patients treated with lumpectomy or mastectomy are presented.
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From page 120... ...
axillary lymph node involved lymph nodes; now strongly involvement considered for 1–3 involved lymph nodes • Internal mammary, • Conventional fractionation (50 Gy/25 supraclavicular, and/ fractions) most commonly used or infraclavicular node • Hypofractionated schedules are less involvement based on frequently used but can be considered imaging or examination • Increases risk of lymphedema and other long-term effects compared to whole breast or partial-breast irradiation Radiation • Age ≥70 years old • Omission of radiation therapy results omission • Tumors ≤2 cm in size in higher rates of in-breast recurrences • Lymph-node-negative but has not been shown to affect overall (clinically or pathologically)
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From page 121... ...
Partial-Breast Irradiation When patients who do not receive radiation therapy after a lumpectomy develop an in-breast tumor recurrence, the recurrence tends to occur near the site of the original tumor. This led to randomized clinical trials comparing whole-breast irradiation with partial-breast irradiation, which is defined as radiation therapy targeting the tumor bed (lumpectomy cavity)
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Radiation Therapy After Mastectomy Postmastectomy radiation is generally used for patients with stage III breast cancer (i.e., 4–9 involved lymph nodes; tumors >5 cm with at
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Furthermore, these studies have also shown that women who have no involved lymph nodes received no benefit from radiation therapy in terms of reduced recurrences or mortality. In women who receive neoadjuvant chemotherapy, data suggest that it is safe to omit radiation therapy only for those women who present with node-negative disease; it remains unknown whether women who receive neoadjuvant chemotherapy that renders negative nodes that were initially positive may omit postmastectomy radiation.
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Partial-breast • Same as above except • Same as above irradiation skin reaction limited to skin in the region of the tumor bed Regional lymph node • Same as above • Same as above irradiation or post- • Pain or discomfort • Increased risk of lymphedema mastectomy radiation swallowing from (7–10% above risk from axillary therapy esophageal irritation surgery) c (particularly left-sided • Delays or complications with cases)
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From page 125... ...
The choice of a chemotherapy regimen for breast cancer depends on a number of factors, including the clinical status of the patient and patient preference. Unlike endocrine therapy, which typically is used after local therapies (i.e., surgery and radiation)
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but always in the context of what additional benefit it may add to endocrine therapy. In invasive breast cancer, adjuvant endocrine therapy is recommended after surgery and radiation (if used)
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In patients with node-positive, ER-positive breast cancer, the decision whether to add chemotherapy to endocrine therapy is based on the number of involved nodes and the patient's menopausal status. In certain situations, particularly for postmenopausal women with limited nodal involvement, there appears to be little benefit from adding chemotherapy to endocrine therapy.
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From page 128... ...
Increasingly, neoadjuvant chemotherapy is being used for TNBC, as this approach allows for (1) clinical trials investigating new therapies in addition to standard therapies to improve the response rate and (2)
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From page 129... ...
It may also include endocrine therapy if the cancer is HR-positive. Despite aggressive multimodality treatment, inflammatory breast cancer has a poor prognosis, with a 5-year survival rate of 52% for women with regional disease and 18% for those with distant disease (ACS, 2019)
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TREATMENT OF METASTATIC BREAST CANCER Metastatic breast cancer at diagnosis (stage IV) is infrequent; most metastatic disease occurs several years after initial diagnosis of earlier stage disease and represents a recurrence of the original breast cancer that has spread to another part of the body, most commonly the liver, brain, bones, or lungs.
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From page 131... ...
The National Comprehensive Cancer Network and other organizations encourage enrollment in clinical trials whenever possible as the best choice for treatment. Treatment for metastatic breast cancer, as with localized disease, is determined by HR and HER2 status, the timing and type of prior therapies, the presence of visceral crisis (i.e., the need to achieve a therapeutic response quickly because of impending or actual organ damage)
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Systemic Treatments Systemic treatments for metastatic breast cancer include the use of endocrine therapies and chemotherapy as well as targeted therapies. In general, treatments are used until there is too much toxicity to continue or until the cancer grows.
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CDK4/6 Inhibitors FDA has approved cyclin-dependent kinase (CDK) 4/6 inhibitors in combination with endocrine therapy for both first-line and second-line treatment of HR-positive, HER2-negative, advanced or metastatic breast cancer.
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Alpelisib is a cyclin-dependent kinase inhibitor which, in combination with endocrine therapy, improves progression-free survival for these metastatic breast cancer patients. The side effects of alpelisib include elevated blood sugars, diarrhea, and rash (André et al., 2019)
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. Radiation Treatment Palliative Radiation Therapy Although the first-line treatment of metastatic breast cancer is systemic therapy, local treatments such as radiation therapy can be used to help improve or palliate a symptom caused by the disease, particularly pain from bone metastases.
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comparing SBRT to standard-of-care therapy (systemic therapy and palliative radiation, if indicated) are pending, and if SBRT proves to be beneficial by improving disease outcomes, it may become the standard of care for patients with limited metastatic breast disease (Chmura et al., 2019)
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From page 137... ...
Many of the long-term and late-onset effects of cancer treatment, such as fatigue or cognitive complaints, may result from a variety of treatments used for local disease. For women with de novo metastatic or recurrent breast cancer, the physical effects often dominate and are influenced by the specific sites of metastatic disease (e.g., bone, lung, liver, or brain)
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Lymphedema Lymphedema (swelling of the arm) on the side associated with breast surgery is more likely to occur in women who had more extensive axillary node surgery (axillary lymph node dissection versus sentinel lymph node dissection)
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Cognitive Impairment Cognitive impairment after breast cancer treatments can be associated with fatigue or may be an independent complaint. While only 15–20% of women may experience this problem, many are unable to do their usual home and professional work due to having difficulty remembering, planning, and multitasking.
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. More information on the treatment of cognitive impairments from cancer treatments can be found in Chapter 9.
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This therapy is given for 5–10 years and is difficult for many women to tolerate. There may be other complications from breast cancer treatment, such as blood clots from tamoxifen or osteoporosis and fracture risk from premature menopause or endocrine therapy.
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2. More than 90% of breast cancer patients present with localized disease that has not spread outside of the breast and regional lymph nodes.
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Meta static breast cancer has significant implications for their prognosis and treatment. For women with de novo metastatic or recurrent metastatic breast cancer, the physical effects often dominate and are influenced by the sites of the metastatic disease (e.g., bone, lung, liver, or brain)
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From page 144... ...
2018. ASTRO guideline on radiation therapy for the whole breast.
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2016. Fulvestrant plus palbociclib versus fulvestrant plus placebo for treatment of hormone-receptor-positive, HER2-negative metastatic breast cancer that progressed on previous endocrine therapy (PALOMA-3)
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2014. Cognitive function after the initiation of adjuvant endocrine therapy in early-stage breast cancer: An observational cohort study.
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2013. Single-fraction radiother apy versus multifraction radiotherapy for palliation of painful vertebral bone metastases equivalent efficacy, less toxicity, more convenient: A subset analysis of radiation therapy oncology group trial 97-14.
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2018. Bisphosphonate use and risk of recurrence, second primary breast cancer, and breast cancer mortality in a population-based cohort of breast cancer patients.
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2017. Estimation of the number of women living with metastatic breast cancer in the United States.
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2017. Olaparib for metastatic breast cancer in patients with a germline BRCA mutation.
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2017. Radiation therapy targets and the risk of breast cancer-related lymphedema: A systematic review and network meta-analysis.
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2015. Psychological adjustment in breast cancer survivors.
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2010. Long-term results of hypofractionated radiation therapy for breast cancer.
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