Life Voyages: Stories of Breast Cancer Survivorship
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 • 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 • 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
Treatment • 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?
Treatment • 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?
Treatment • 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?
Treatment • Why do people get treated so differently? • Can I trust my physicians? • Is my cancer one that I am likely to survive?
Ductal Carcinoma in situ Text Text
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? • Evolution in surgical treatment • Changes in radiation delivery and duration • Learning a tumor’s personal biology: the evolution in adjuvant systemic treatment
The Evolution in Surgical Care of Breast Cancer
Halsted Mastectomy • Entire breast • Axillary lymph nodes • Pectoralis major and minor muscles Removed
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
Lumpectomy 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 Contraindications to Breast Conservation • 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.”
Radiotherapy 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
2000’s This recent evolution to Partial Breast Irradiation parallels the surgeon’s discovery that lumpectomy yields equivalent outcome to mastectomy in the majority of patients.
1962 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