breast cancer 101 for co-survivors

Breast Cancer 101 for Co-SurvivorsDeanna J. Attai MD, FACS

David Geffen School of Medicine, UCLA@DrAttai

• Patient is overwhelmed• Needs your help, support,

stability

• You are overwhelmed• New terminology, new doctors,

many decisions to make

The Co-Survivor’s Challenge

• Remember to breathe!!!• Breast cancer is a “mental emergency”

(not medical)• You have time to gather information,

make decisions

• The treatment team• Understanding the pathology report• Treatment options and side effects• Unique considerations: fertility, genetics• Metastatic disease• Survivorship• How to help

• Cancer physicians: • Breast surgeon, medical oncologist,

radiation oncologist• Primary care physician, gynecologist• Nursing:

• Nurse Navigator, oncology nurses • Psycho-Social Support

• Social Work, therapist, spiritual care• Other Clinicians

• Genetics, nutrition, physical therapy, research staff, other

Multidisciplinary Team Approach

“2.5cm grade 3 invasive ductal carcinoma ER/PR negative, Her2/neu not over-expressed”

Breast cancer in young women more likely higher stage, higher grade, more aggressive cell type

Understanding the Pathology Report

Cell Type:• Ductal

• ~80-85% of all breast cancers• Lobular

• Less likely to form a well defined mass

• Treatment is based on stage, biology features – not cell type

Understanding the Pathology Report

0: Ductal carcinoma in-situ / DCIS / non-invasive

I: Tumor < 2cm, no spread to lymph nodesII: Tumor 2-5 cm or spread to underarm nodesOR – Tumor >5cm, no spread to lymph nodesIII: Tumor > 5cm and spread to multiple underarm nodes OR – Tumor growing through skin or muscle

IV: Spread outside breast: liver, lungs, brain, bone

~2.5cm = 1 inch

Cancer Stage: Tumor size, Spread

Measure of cell appearance Higher grade tumors may have more aggressive behavior

• Grade 1 – low grade - well differentiated • Grade 2 – intermediate grade – moderately differentiated• Grade 3 – high grade – poorly differentiated

Cell Grade

Estrogen / Progesterone Receptors

• Estrogen binds to receptor, signals cell growth

• ER+(positive): cells have receptor, can be stimulated by estrogen

• ER- (negative): cells have lost receptor, don’t respond to estrogen

Her2/neu

• Protein on cell surface• Associated with more aggressive growth • Her2/neu positive = “over-expressed”

• May include:• Blood tests• Body imaging to look for metastatic disease (Stage II – III)• Echocardiogram (ultrasound of heart) before

chemotherapy or targeted therapy• Genetic testing• Fertility assessment

Pre-Treatment Evaluation

• ~10-15% of breast cancers linked to DNA mutation• More likely in younger women even w/o family history• BRCA 1/2 genes and many others• Results may impact treatment

• Consider bilateral mastectomy, removal of ovaries

• Results may impact other family members

Genetic Testing

“I didn’t know I wanted kids until you told me I might not be able to have them”

• Consider before chemotherapy:• Reproductive endocrinologist• Egg harvesting +/- embryo • Lupron during therapy

Fertility

Pregnancy after Breast Cancer

• Retrospective, 1207 patients• History of BC, became pregnant

after diagnosis• Matched for ER, nodal status,

adjuvant therapy, age at diagnosis < or > 35

J Clin Oncol 2013;31(1): 73-79

Pregnancy after Breast CancerPOSITIVE Study

• Pregnancy Outcome and Safety of Interrupting Therapy for Women with Endocrine ResponsIVE Breast Cancer

• Evaluate safety, pregnancy outcomes w/interruption of endocrine therapy

• Patients complete 18-30 months of endocrine therapy• Stop endocrine therapy for up to 2 years for pregnancy, delivery,

breast feeding or failure to conceive, then restartwww.clinicaltrials.govALLIANCE #A221405

• Local (breast) –breast and lymph node surgery, radiation• Remove the main tumor • Reduce chances of it growing back in the breast

• Systemic (whole body) – chemotherapy, hormone blockers• Reduce likelihood of cancer cells surviving an growing outside breast• Liver, lung, bone, brain most common areas of spread

Breast Cancer Treatment

• Outpatient surgery, can be combined w/reduction, lift• Potential for change in breast shape, size, numbness of skin• 2nd surgery may be required to get clear margin• Radiation treatment necessary • If cancer comes back in breast, usually need mastectomy• Continued surveillance with mammogram, other imaging

Lumpectomy

• Removal of entire breast• 1-5 day hospital stay; drain tubes 7-10 days• Nipple sparing may be an option• If reconstruction: 2-3 procedures may be needed• Radiation if larger tumor, spread to nodes• 1-5% chance of cancer returning at site• Does not keep cancer from spreading• Permanent numbness, post-mastectomy pain syndrome

Mastectomy

• Does not keep cancer from spreading• Does not keep cancer from coming back• Double complication rates (20-40%)• ~30% long term body image, sexual function issues• Most appropriate if BRCA gene mutation

Contralateral Prophylactic Mastectomy - CPM

• Sentinel node biopsy / dissection: removal of 1-4 underarm nodes • Axillary node dissection may be recommended if cancer has already

spread to underarm nodes

• Potential complications: numbness of the underarm / back of arm, lymphedema (long term swelling), pain, limitation in movement

• Lymphedema:• 5-8% with sentinel node biopsy• 15-30% with axillary node dissection• Radiation therapy also adds to risk of lymphedema

Lymph Node Surgery

• Almost always recommended after lumpectomy• After mastectomy if large tumor, spread to nodes• 5 days/week, 3-6 weeks• Potential side effects:

• Skin sensitivity, occasionally mild burn• Change in skin color, skin thickening, long term scarring• Fatigue during treatment

Radiation Therapy

• Usually need mastectomy if cancer returns after lumpectomy-radiation

• Radiation can complicate future reconstruction

Radiation Therapy

• Spread to lymph nodes or other areas of the body• More aggressive forms of cancer even with no spread

• Triple negative, Her2/neu positive, Elevated Ki67, advanced stage

• Additional genomic testing (Oncotype Dx, Mammaprint) may be used to clarify need for chemo

• Neoadjuvant (before surgery) or adjuvant

Systemic / Whole Body TherapyChemotherapy

• Given through intravenous line, port may be recommended• Treatment schedule, number of treatments varies • Common side effects:

• Fatigue Hair Loss• Neuropathy (nerve damage) Nausea / vomiting• Poor appetite Mouth sores• Decreased blood counts/infection Infertility

Systemic / Whole Body TherapyChemotherapy

• Trastuzumab (Herceptin) and Pertuzumab (Perjeta)• Targeted antibody therapy to Her2/neu protein

• Given with standard chemotherapy, often before surgery• Fatigue• Rash• Diarrhea• Heart failure (uncommon, usually reversible)

• Trastuzumab continues every three weeks for one year

Systemic / Whole Body TherapyTargeted Therapy

• Tamoxifen• Blocks estrogen receptor, pre- or post-menopausal • 5-10 years, may be combined w/lupron• Potential side effects:

• Hot flashes, mood swings, depression• Vaginal discharge, ovarian cysts, irregular bleeding• Blood clots (more common if overweight, smoker)• Uncommon – uterine cancer

• Some antidepressants might interfere with action

Systemic / Whole Body TherapyHormonal Therapy

• Aromatase Inhibitors• Blocks production of estrogen• Postmenopausal, 5-10 years• Potential side effects:

• Hot flashes, mood swings• Vaginal dryness• Joint and bone pains, bone loss / osteoporosis• Decreased libido• “Chemobrain”


• ~30% of patients stop treatment due to side effects• May have significant effect on body image, sexual relations• Discuss w/ partner, physician• Role for acupuncture, meditation, pelvic floor physical therapy


• Spread outside of the breast – Stage IV• Common sites: lungs, bone, liver, brain• Not curable but often treatable

• Treatment can include chemotherapy, targeted therapy, and/or endocrine therapy

• Treatment may include radiation therapy, surgery • Clinical trials / research

Metastatic Breast Cancer

• Focus shifts from active treatment to surveillance, health maintenance, management of side effects

• Congratulations – you made it!• “Go live your life”

SurvivorshipLife After Treatment

• Can be a time of intense stress• Role in family, relationship, work, school has

changed• Pressure to get back to “normal”• Body image, concern about recurrence,

ongoing pain or other side effects


• ”Survivor” not universally embraced• Some can’t stand the pink• Battle metaphors (warrior, fighter)• Pinkwashing


• Limited only by your time and imagination• Transportation and company for appointments• Help with household chores• Picking up groceries or prescriptions• Cooking meals• Child care

How To HelpDuring and After Treatment

Reinforce Healthy Habits

• Everyone wants and needs different things• Be truly present• Let the patient direct you

• Don’t forget self-care

breast cancer 101 for co-survivors

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