Breast Health. Program Objectives. Facts About Breast Cancer in the United States

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1 Breast Health Meridian Cancer Care Yolanda Tammaro, M.D. Meridian Medical Group- Specialty Care Breast Surgery, Ocean Medical Center Program Objectives Participants will: Learn some basic breast cancer facts and statistics as it relates to our demographic Understand the risk factors for breast cancer Learn the various methods of early detection Learn about the different types of breast cancer Learn about equipment and technology Learn of services offered & current work at Ocean Medical Center Learn about real world patient scenarios Facts About Breast Cancer in the United States In 2016 it is estimated that 246,660 women in the US will be diagnosed with breast cancer. About 40,000 women will die from the disease this year. African American women have the highest death rate. It rarely occurs in men but when it does it tends to be diagnosed at a later stage. 1

2 Facts One out of eight women in the US will develop invasive breast cancer in her lifetime. The chance of dying from breast cancer is about 1 in 36 or 3%. Breast cancer death rates are going down. This is due to finding cancer earlier and improved treatment. Every woman is at risk for breast cancer. The risk of developing breast cancer increases as a woman ages. Breast Health Care: The Need in New Jersey Rising total number of cases from in Ocean County for female breast cancer. More cases in Ocean County than Monmouth County despite Monmouth County having a higher population at risk. Source: NJ State Cancer Registry, Understanding Risk Factors Gender Age Personal history of breast cancer Family history of breast cancer Genetics Early 1 st menstrual period Having children over the age of 30 years old Having no children at all History of breast biopsies Atypical ductal hyperplasia Atypical lobular hyperplasia Lobular carcinoma in situ Hormone replacement therapy Alcohol usage Obese or overweight after menopause Late menopause 2

3 Methods of Early Detection Breast self exam (BSE) Clinical breast exam (CBE) Screening Breast Self Exam (BSE) Breast self-exam (BSE) is not recommended as a screening tool for breast cancer. However, it is important to become familiar with the way your breasts normally look and feel. Knowing what is normal for you may help you see or feel changes in your breasts. - Susan G. Komen It is very important for women to know what is normal for their breast. When performing a breast self exam, check for: Lumps Skin changes Nipple discharge Nipple Inversion Over 80% of breast lumps are benign, but any breast lump must be evaluated by a physician Follow-up biopsy is often recommended. Clinical Breast Exam (CBE) A clinical breast exam (CBE) is a physical exam done by a health care provider as part of your regular medical check-up. Your provider should carefully feel your breasts and underarm for any changes or abnormalities (such as a lump). -Susan G. Komen CBE should be performed every 3 years starting at age 20 and every year starting at age 40. 3

4 Get Screened Ask your doctor which screening tests are right for you if you are at higher risk. Have a mammogram every year starting at age 40 if you are at average risk. Breast Health Imaging Technology and Equipment Digital mammography: Screening & Diagnostic Breast Ultrasound Breast MRI Tomosynthesis 3D Imaging Nuclear medicine for sentinel lymph node biopsies Savi Scout for future localizations of lumps Breast Cancer Types Ductal Carcinoma in situ (DCIS) Invasive (infiltrating) ductal carcinoma (IDC) Inflammatory Breast Cancer (IBC) Invasive lobular cancer 4

5 Services offered Office Services High Risk Breast Cancer Assessment Ultrasound in office equipment to examine breast lesions or lumps Biopsies punch biopsies & core biopsies Incision and Drainage of Breast Abscesses Contura balloon insert to limit radiation therapy to only 5 days for patients Hospital Surgery Services Lumpectomy Wire localized lumpectomy Sentinel node biopsy Nipple/duct explorations Mastectomy Nipple and skin sparing mastectomy Oncoplastic simultaneous breast reduction with wide lumpectomy DIEP flap Reconstruction including tissue expander implant & DIEP, TRAM, latissimus flap Current work at Ocean Medical Center Work closely with a clinical team including pathologists, oncologists and radiation oncologists to improve patient outcomes through a collaborative plan of care. Each clinical team is composed of a specialized, dedicated team of cancer experts from different disciplines who pool their knowledge to review cases and reach a consensus regarding the best course of treatment for each patient Case 1 47 Y/O F felt lump in her left breasat on self breast exam. Mammogram revealed a dense mass with suspicious calcs and sono showed highly suspicious 1x1 cm spiculated solid mass. Left breast US guided core biopsy was rec and performed 5

6 Case 1 PMH: HTN PSH: Tonsillectomy Meds: Losartan All: None Breast Ca Risk Factors: 11 at menarche, premenopausal, No HRT, 23 yrs old at first live birth, mother s twin sister with breast ca at 49 Social: Social ETOH, no smoking, no drugs Case 1 PE AVSS Left breast: vaguely palpable, mobile mass at 1:00 3 cmfn, no n d/c or inv, no skin changes Right breast: no masses, no n d/c or inv, no skin changes Left axilla: small mobile LN Right axilla: no LAD Case 1 6

7 Case 1 Left Ultrasound Guided Core Needle Biopsy Invasive ductal cancer, ER +, PR+, Her2neu negative Case 1 Discussion regarding surgical options Preference Bilateral NSM with sentinel lymph node biopsy Genetic Counseling referral for BRCA testing - negative 7

8 Post-op Case 1 Outcome Left breast with 11mm residual IDC, all sentinel nodes negative for breast cancer Right breast no cancer, small focus of atypical ductal cancer Case 2 72 y/o F no breast related complaints. Screening mammo- subtle nodular density in the left breast Ultrasound nodule at 6:00, 2 cm fro the nipple, 7x8x4mm Ultrasound guided core biopsy recommended 8

9 Case 2 PMH: hemolytic anemia, htn PSH: none Meds: diovan, folic acid All: none Social: No ETOH, no smoking, no drugs Breast Ca risk factors: Menarche 9.5 yrs, menopause 54 yrs, one breast biopsy, 18 at first live birth, no family history of breast ca Case 2 PE AVSS Bilateral Breasts - No masses, nd/c or inv, no skin changes Bilateral Axilla - No LAD Case 2 9

10 Case 2 Left Ultrasound Guided Biopsy Invasive ductal Cancer, ER pos PR pos, Her2neu negative Case 2 Discussion of Surgical options Chose Left breast lumpectomy with SLN biopsy Path 6mm residual IDC, all sentinel nodes neg for cancer, all margins negative 10

11 Radiation Therapy Radiation treatment AFTER breast conserving surgery (lumpectomy) PREVENTS RECURRENCE, IMPROVES Breast Cancer and Overall Survival POSSIBLE TREATMENT SCHEDULES: Standard: 6.5 weeks (26 Whole breast + 7 Boost) Accelerated: 4 weeks (16 treatments whole breast) Accelerated Partial Breast: 1 week (10 treatments, 2/day) Research Protocol: Variable Accelerated Partial Breast Irradiation Suitable Candidates Suitable Caution Contraindicated Age Age 60 yo yo <50 yo BRCA status BRCA-1/2 positive T-stage T1 T0 or T2 T3-T4 or extensive DCIS ILC (lobular ILC cancer) LVSI Suspicious LVSI Focal or limited LVSI Extensive LVSI ER status ER positive ER negative Centricity Unicentric Multicentric Focality Multifocal 2 cm Multifocal cm Multifocal > 3cm EIC (intraductal EIC > 3cm component) Nodal status LN negative LN positive Chemo Neoadjuvant or concurrent chemo Surgical Margins (SM) SM 2mm SM < 2mm SM positive Contura Balloon Catheter 11

12 Comparing Treatment Options Whole BreastRadiation Treat from outside in Pro: Whole breast treated No additional surgery Boost to surgery bed May include some lymph nodes Con: Inconvenience (45 day process) More skin reaction Treatment other organs Partial Breast Radiation Treat from inside out Pro: Targeted Less likely reaction/fibrosis Convenient (10 day process) Completed before chemo Con: Only part of breast treated Additional biopsy procedure Possible breast tissue damage Insertion Process 1. NPO after midnight. Insertions are scheduled on Thursdays 8 am and Fridays 9 am. 2. Ativan or Valium oral dose 1 tab one hour before procedure with sips of water. 3. Must have a driver on the day on insertion, no driver needed for duration of treatment 4. Procedure is done with local anesthesia, with patients laying on their side. The procedure may take one hour, but generally is done in a shorter time period. 5. We will provide oral pain medication and antibiotic prescriptions for post procedure. No showers until balloon is removed. Insertion of the Balloon 12

13 Outcomes: Mammosite trial Treatment efficacy with accelerated partial breast irradiation (APBI): final analysis of the American Society of Breast Surgeons MammoSite( ) breast brachytherapy registry trial. Shah C, Badiyan S, Ben Wilkinson J, Vicini F, Beitsch P, Keisch M, Arthur D, Lyden M. Ann Surg Oncol Oct;20(10): doi: /s Epub 2013 Aug patients, med follow-up 5.5 years IBTR 2.8%, 5 Year rate IBC 3.7%, DCIS 4.1% Trend to fail: Positive margins, cautionary/unsuitable GUIDELINE ~90% excellent/good cosmetic outcomes up to 7 years out Fat necrosis 2.5% Infections 10% Seroma symptoms about 13%, resolved by 2 years Remember, if detected early, not only can breast cancer often be treated effectively with surgery that preserves the breast, but it also increases your chance of a cure. Five year survival after treatment for localized breast cancer can be as high as 99%. Sources: The Susan G. Komen Breast Cancer Foundation. American Cancer Society GE Healthcare Questions/ Comments? Thank you! Yolanda Tammaro, M.D. Breast Surgery, Ocean Medical Center 1610 Route 88, Suite 203 Brick, NJ Phone: Fax: