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Life Voyages: Stories of Breast Cancer Survivorship Why write a book? Do we not all ask ourselves: Could I face cancer? Would I handle cancer with grace and dignity? Would I loose control? Would my family and friends be there for me ? An Altered Image

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Life Voyages:

Stories of Breast Cancer Survivorship

do we not all ask ourselves
Do we not all ask ourselves:
  • Could I face cancer?
  • Would I handle cancer with grace and dignity?
  • Would I loose control?
  • Would my family and friends be there for me?
an altered image
An Altered Image
  • Could I bear with dignity my bald head if I needed chemotherapy?
  • Will my spouse still love my altered body with same rapture?
  • Will I look to the world like a cancer patient?

Sheryl Crow

“We talk about defining moments, but I think nothing can define you. They're all refining moments. You're constantly refining yourself and refining your life."

our history
Our History
  • Family history of breast cancer:
    • Do I face my diagnosis when the inevitable is finally here?
    • Will I be lucky enough to escape the curse?
  • What life experiences will I turn to and how will they guide my response?

Who is at risk?

One in eight women get breast cancer


High Risk Individuals

  • Personal history of breast cancer
  • Women with previous biopsy demonstrating:
  • Atypical ductal hyperplasia
  • Lobular carcinoma in situ
  • BRCA 1 or BRCA 2 positive genetic testing

Strong family history of pre-menopausal breast cancer

  • History of chest radiation for lymphoma
  • Am I ready and adequately educated to make complex treatment choices?
  • Why must I decide?
  • Whose body is it anyway: why do my family and friends all have an opinion?
  • How many opinions do I need?
  • How do I choose my physicians?
  • Will they still be there for me when the acute phase of treatment is completed?
  • Do I want to be part of the latest research protocol: am I comfortable with randomized treatment choice?
  • Will the pivotal discovery occur too late to help me?
  • Why do people get treated so differently?
  • Can I trust my physicians?
  • Is my cancer one that I am likely to survive?
is there anyone like me with a cancer like mine
Is there anyone like me with a cancer like mine?
  • How did they get through treatment?
  • What treatment did they choose?
  • How do they look?
  • Are they all right?
  • Will I be all right?
how is breast cancer treatment changing
How is breast cancer treatment changing?
  • Evolution in surgical treatment
  • Changes in radiation delivery and duration
  • Learning a tumor’s personal biology: the evolution in adjuvant systemic treatment

Halsted Mastectomy

  • Entire breast
  • Axillary lymph nodes
  • Pectoralis major and minor muscles



Henri Francois Le Dran (1685 - 1773)

Wrote that axillary lymph node involvement

indicates a worse prognosis

Le Dran believed breast cancer must spread through

the lymphatics to lymph nodes and then into

the general circulation.


Why did American surgeons embrace the Halsted Mastectomy?

1894 Halsted reports on 50 cases of breast

cancer treated with Halsted mastectomy

Recurrence rate of 6%

In comparison, European experience with

Von Volkman mastectomy

Recurrence rates 51 - 82%


Modified Radical Mastectomy

  • Removes entire breast
  • Removes axillary lymph nodes
  • Leaves pectoralis major muscle
  • May leave or remove pectoralis minor

Umberto Veronesi

WHO Study

  • Halsted Mastectomy
  • Modified Radical Mastectomy
  • Quadrentectomy with axillary dissection

1981 NEJM: No survival difference


Era of Evidence Based Medicine

  • Objective comparison of efficacy of different therapeutic options
  • Statistical power derived from inclusion of large number of patients from multiple institutions


Preserves breast

Excision designed to remove cancer

and margin of normal tissue

Axillary dissection performed through

seperate incision in armpit

Requires addition of radiation therapy


Prior therapeutic radiation to the involved breast

  • Presence of 2 or more distinct cancers involving different quadrants of the breast


to Breast


  • Large tumor volume-to-breast volume ratio good cosmetic outcome
  • Patient in first or second trimester of pregnancy
  • Collagen-vascular disease
  • Severe pulmonary or coronary disease

1990’s: The Next revolution

Sentinel Lymph Node Biopsy

Accurate axillary staging

without removing all the axillary nodes

in early stage breast cancer patients


Armando Giuliano

1995 Presented use of

sentinel lymph node biopsy

in breast cancer staging


Sentinel Lymph Node Biopsy

  • injection of radioactive tracer
  • vital blue dye injection
  • immediate pathologic assessment
  • complete staging axillary dissection

if tumor found in sentinel lymph node(s)

Traces those lymph nodes that receive lymphatic

drainage first from the organ they drain

Provides more accurate staging
  • Decreased post-operative discomfort
  • Decreased incidence of lymphedema

Sentinel Lymph Node Biopsy

2-4% after SLNB

10-25% after ALND


Sentinel Lymph Node Biopsy

Occult metastases: 5 year survival

79% with occult mets

88% without occult mets

Micrometastases: Tumor deposits of less

than 2mm No survival difference

If SLN is positive,

Additional positive LN are

found in 30 - 60% of patients


Dr. D Hayes Agnew

“I do not despair of carcinoma being

cured somewhat in the future, but

this blessed event will never be

wrought by the knife of a surgeon.”



1903 Alexander Graham Bell

Suggested radium could be placed in a

glass tube and inserted into a tumor

1908 George Chicotot

Attempted to use radiotherapy for breast cancer

1919 Claude Regaud

Promoted fractionation of radiation dose


Mammosite Partial Breast Irradiation

  • 1 week vs 6 weeks of therapy
  • No difference in “elsewhere” recurrences
  • Less breast tenderness and long-term asymmetry
  • 3 year data: 1.2% recurrence rate
  • Improved coordination with chemotherapy


This recent evolution to Partial Breast Irradiation parallels

the surgeon’s discovery that lumpectomy yields

equivalent outcome to mastectomy

in the majority of patients.



Bloom reported the natural history

of untreated breast cancer

Survival ranged from months to decades


The Unanswered Question:

Why such variability in the natural

course of breast cancer?


Tumor Characteristics

  • Hormone receptor status
  • Grade
  • Size
  • Her2neu

Onco Type DX

  • 21 gene assay, used in ER +, LN - patients
  • 65% of women of breast cancer patients have lymph node-negative disease at diagnosis
  • 85% of these women are alive and free of recurrence at 10 years
  • Patients with low risk (<18) score, 50% of those tested, have no benefit from chemotherapy

Stem Cells

Necessary for cell propagation

Not all metastases contain stem cells

Next step: Develop therapies

that will target only stem cells

how is breast cancer discovered
How is breast cancer discovered?
  • Feel a lump
  • Find skin dimpling
  • A persistent especially bloody nipple discharge
  • Flaking, hardening of the nipple
  • Breast redness without pain and unresponsive to antibiotics
breast self examination
Breast Self Examination
  • Feel a lump in the breast or axilla
  • Feel an assymetric prominence
  • See skin retraction
  • Find nipple discharge, excoration or retraction
  • Find breast erythema or edema


Only 75% of cancers are revealed

Fatty breasts 98%

Very dense breasts 48%

Training for Mammo

After a Mammo


The Future


Uses intravenous contrast to identify areas of

increased blood flow

Pitfall: False positives

Hormonal stimulation causes increased blood flow

Misses some low grade cancers and DCIS


Future Treatment Evolution

  • Individualized diagnosis
  • Individualized therapy
  • Survivorship