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CES201901: Breast cancer 2 (adjunct presentation)
This document summarizes information about breast cancer treatment from diagnosis through post-treatment follow up. It provides tables on global and Colombian breast cancer incidence and mortality statistics. It also outlines the typical workup, testing, staging, and treatment approaches for different stages of breast cancer, including surgical, radiation, chemotherapy and hormonal options. The main toxicities of common breast cancer drugs are also summarized.
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CES201901: Breast cancer 2 (adjunct presentation)
- 1. CES2019.01 – Cáncerde mama II – Visión del oncólogo Mauricio Lema Medina MD @Onconerd
- 2. Topics • Invasive breastcarcinoma
- 3. Objetivo • Obtener unconocimiento GENERAL del manejo USUAL de pacientes con las patologías a discutir desde la sospecha diagnóstica, hasta el las pautas de seguimiento post-tratamiento, pasando por los aspectos más relevantes de tratamientos con intención curativa.
- 4. Cancer New cases(World) Deaths (World) New cases (Colombia) Deaths (Colombia) Breast 2’088.849 (2) 626.679 (5) 13.380 (1) 3.702 (4) Prostate 1’276.106 (4) 358.989 (8) 12.712 (2) 3.166 (5) Lung 2’093.876 (1) 1’761.007 (1) 5.856 (5) 5.236 (2) Stomach 1’033.701 (5) 782.685 (3) 7.419 (4) 5.505 (1) Colon & rectum 1’849.518 (3) 880.792 (2) 9.140 (3) 4.489 (3) Lymphoma (NH) 509.990 (10) 248.724 (11) 4.170 (6) 1.676 (10) Uterine cérvix 569.847 (8) 311.365 (9) 3.853 (7) 1.775 (9) Leukemia 437.003 (12) 309.006 (10) 3.126 (8) 2.192 (7) Ovarian 295.414 (17) 184.799 (14) 2.414 (9) 1.252 (11) Pancreas 458.918 (11) 402.232 (7) 2.311 (10) 2.142 (8) Liver 841.080 (6) 781.636 (4) 2.279 (11) 2.216 (6) Multiple mieloma 159.885 (21) 106.105 1323 (14) 806 (14) Esophagus 572.034 (7) 508.585 (6) 922 (15) 710 (15) Hodgkin 79.999 (25) 26.167 743 (16) 216 Brain 296.851 (16) 241.037 (12) 1884 (12) 1.176 (12) Gallbladder 219.420 (19) 165.087 (17) 1657 (13) 1.104 (13) All 18’078.957 9’555.027 101.893 46.057 http://gco.iarc.fr/today/
- 5. Cancer New cases(World) Deaths (World) New cases (Colombia) Deaths (Colombia) Breast 2’088.849 (2) 626.679 (5) 13.380 (1) 3.702 (4) Prostate 1’276.106 (4) 358.989 (8) 12.712 (2) 3.166 (5) Lung 2’093.876 (1) 1’761.007 (1) 5.856 (5) 5.236 (2) Stomach 1’033.701 (5) 782.685 (3) 7.419 (4) 5.505 (1) Colon & rectum 1’849.518 (3) 880.792 (2) 9.140 (3) 4.489 (3) Lymphoma (NH) 509.990 (10) 248.724 (11) 4.170 (6) 1.676 (10) Uterine cérvix 569.847 (8) 311.365 (9) 3.853 (7) 1.775 (9) Leukemia 437.003 (12) 309.006 (10) 3.126 (8) 2.192 (7) Ovarian 295.414 (17) 184.799 (14) 2.414 (9) 1.252 (11) Pancreas 458.918 (11) 402.232 (7) 2.311 (10) 2.142 (8) Liver 841.080 (6) 781.636 (4) 2.279 (11) 2.216 (6) Multiple mieloma 159.885 (21) 106.105 1323 (14) 806 (14) Esophagus 572.034 (7) 508.585 (6) 922 (15) 710 (15) Hodgkin 79.999 (25) 26.167 743 (16) 216 Brain 296.851 (16) 241.037 (12) 1884 (12) 1.176 (12) Gallbladder 219.420 (19) 165.087 (17) 1657 (13) 1.104 (13) All 18’078.957 9’555.027 101.893 46.057 http://gco.iarc.fr/today/
- 15. Workup – StagesI-IIB Comments H&P Diagnostic bilateral mammogram Breast ultrasound Pathologic review Determination ER / PR Determination Her2 Genetic counseling High risk for hereditary cancer Breast MRI Optional Counseling for fertility In premenopausal; pregnancy test Further workup as needed Complete blodd count, liver function tests Bone scan if symptoms or high alk-phosphatase Abdomen CT in high alk-phosphatase or symptoms Chest CT if pulmonary symptoms Breast cancer https://www.nccn.org
- 16. Workup – StagesIIIA T3, N1, MO Comments H&P Diagnostic bilateral mammogram Breast ultrasound Pathologic review Determination ER / PR Determination Her2 Genetic counseling High risk for hereditary cancer Breast MRI Optional Counseling for fertility In premenopausal; pregnancy test Complete blood count Liver function tests, alk-phosphatase Chest / abdomen +/- pelvis CT Bone scan PET-CT Optional Breast cancer https://www.nccn.org
- 17. Workup – Priorto preoperative systemic therapy Comments H&P Diagnostic bilateral mammogram Breast ultrasound Pathologic review Axillary assessment Physical exam, ultrasound or other imaging as necessary, and percutaneous biopsy of suspecious nodes Determination ER / PR Determination Her2 Genetic counseling High risk for hereditary cancer Breast MRI Optional Counseling for fertility In premenopausal; pregnancy test Further workup as needed Complete blodd count, liver function tests Bone scan if symptoms or high alk-phosphatase Abdomen CT in high alk-phosphatase or symptoms Chest CT if pulmonary symptoms Breast cancer https://www.nccn.org
- 18. Clinical suspicion Suspiscious mammo… Breastskin changes Nipple abnormalities Core-needle biopsy (ie US-guided) Breast mass TNM/Stage/Biology Stage I Stage II Resectable stage III Unresectable stage III Metastatic
- 19. Luminal Her2+ TNBC StageI LRT (RT if BCS) Genomic (Chemo if HR) Hormonal LRT (RT if BCS) Paclitaxel + Trastuzumab Hormonal if HR+ LRT (RT if BCS) Adjuvant chemotherapy Stage II LRT (RT if BCS) Genomic (Chemo if HR) Hormonal LRT (RT if BCS) AC, followed by Paclitaxel + Trastuzumab Hormonal if HR+ RT if LN+ LRT (RT if BCS) Adjuvant chemotherapy RT if LN+ Stage III Neoadjuvant AC-Paclitaxel Surgery – RT Hormonal Neoadjuvant AC-Paclitaxel + Trastuzumab Surgery – RT If not-pCR: T-DM1; else, Trastuzumab Hormonal if HR+ Neoadjuvant AC- Paclitaxel +/- Carboplatin Surgery – RT If not-pCR: Capecitabine Low-Risk Metastatic (Bone and soft tissue metastases, only) Ovarian ablation (premenopausal) + AI + cdk4/6 inhibitor + Denosumab CLEOPATRA: Docetaxel + Trastuzumab + Pertuzumab + Denosumab Single-agent paclitaxel Visceral crises Single/combined chemo, followed by hormone CLEOPATRA Single/combined chemo Breast cancer pattern of care LRT: Loco-regional therapy (ie, surgery +/- radiation); RT: radiation therapy; BCS: breast-conserving surgery, HR: Estrogen or progesteron receptor positive, AC: Doxorubicin + Cyclophosphamide; LN+: positive regional lymph-nodes; pCR: pathologic complete response, T-DM1: Trastuzumab emtansine; AI: Aromatase inhibitor
- 21. Drug MOA Includedin Main toxicities Doxorubicin Topoisomerase II inhibitor (anti DNA agent) A in AC Alopecia Nausea/Vomiting Myelosuppression Mucositis Cardiac toxicity, 2ry leukemias Cyclophosph amide Alkilating agent (anti DNA agent) C in AC Myelossuppression … See doxorubicin Paclitaxel Anti microtubule agent (mitosis poison) Paclitaxel, alone or in combination Muscle and joint pain Myelosuppression Peripheral neuropathy Capecitabine Antimetabolite (anti Thymidilate synthase) Capecitabina, alone or in combination Diarrhea Hand-foot syndrome Myelosuppression Trastuzumab Anti HER-2 monoclonal antibody In many Her2+ settings Cardiac toxicity (reversible) T-DM1 Anti Her2 - Antibody-drug conjugate In many Her2+ settings Neuropathy Thrombocytopenia Cardiac toxicity
- 22. Drug MOA Includedin Main toxicities Tamoxifen Selective estrogen receptor modulator Anti estrogen for both premenopausal, and post menopausal women Hot flashes Weight gain Thromboembolic complications Corpus uteri neoplasms AI Anti-estrogen through aromatase inhibition Alone, or in combination (Anastrozol, Letrozol, Exemestane) Hot flashes Joint pain Osteoporosis Dyslipidemia Fulvestrant ER inactivator Alone, or in combination Hot flashes Injection-site reaction Cdk4/6 inhibitor Cell-cycle inhibitor Alone (abemaciclib) In combination with AI or Fulvestrant (ribociclib or palbociclib) Neutropenia Prolongued QT Diarrhea, etc.
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