Breast Cancer

• Understanding the disease
• Treatment options
• Side effects of treatment

Stephen Shamp, MD MSEE

David Bloom, MD PhD

Matthew Culbert, MD

Stage is based on the tumor size �(T1 – T4)

Tis = DCIS

T1 ≤ 20mm

T1a ≤ 5mm

T1b = 6 to 10mm

T1c =11 to 20mm

T2 = 21 – 50 mm

T3 > 50 mm

T4 = Invading skin, muscle, or both

N0 = no nodes �N1 = 1 -3 nodes �N2 = 4 – 9 nodes�N3 = 10 nodes �or SCV or IMC

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Stage is based on lymph node spread �(N1 – N3)

Breast Cancer Anatomic Stage

Clinical Prognostic Stage includes grade and biomarkers

Grade – how mutated the cells have become. The closer the cells resemble normal breast cells, the less serious (slower growing, less likely to spread.)

Grade 1 or well differentiated – slow growing, most favorable (Nottingham � Score or NS 3-5)

Grade 2 or moderately differentiated – most common, average (NS 6-7)

Grade 3 or poorly differentiated – fast growing, more serious (NS 8-9)� Proliferative Index (Ki-67) Low (<10%) Intermediate (10-20%) High (>20%)

Hormone Receptors – normal breast cells are sensitive to hormones and have positive receptors for estrogen (ER+) or progesterone (PR+). If the hormone receptors are present (called positive) the cancer is less serious and more likely to respond to a hormone therapy drug like tamoxifen (Nolvadex), Arimidex (anastrazole) , Femara (letrozole) or Aromasin (exemestine).

HER-2/Neu Abnormal expression of HER-2/Neu is an important prognostic and therapeutic biomarker. This may effect the choice of chemotherapy drugs used (like Adriamycin, Taxol or Herceptin/Perjeta)

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Breast Conservation

Lumpectomy (remove the cancer with a small rim of normal tissue, clear margins)

• For early stage breast cancer, outcomes after lumpectomy plus radiation are equal to mastectomy

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Sentinel node biopsy will often be performed at the same time

At the time of the lumpectomy the surgeon tries to remove the cancer with a margin of normal breast tissue around the mass

X-ray image of the lumpectomy specimen

www.nccn.org

Then a decision about the need for radiation and how large should the radiation target be

Radiation for DCIS

Is Radiation necessary after mastectomy?

Is Radiation necessary after neoadjuvant chemotherapy?

What About Breast Reconstruction?

According to the NCCN (3.2019)

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“Reconstruction can be performed at the time of the mastectomy (immediate) or delayed.

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Radiation increases the risk of implant capsular construction and may have a negative impact on cosmesis in some (but not all studies)

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When radiation is planned most surgeons prefer expanders at the time of surgery then completion of radiation then final surgery.”

What About Breast Reconstruction?

CT simulation (planning session)

• We will build a cradle to hold you in the same position with each treatment.
• Temporary or permanent marks will be made
• CT images are obtained and then imported into the treatment planning computer
• For left breast cancer, deep inspiratory breath hold (DIBH) is often used to reduce radiation to the heart

Radiation beam skims over the surface of the chest wall, ribs and luring

Logistics of Whole Breast Radiation:

• Usually 16-20 daily treatments
• Treatment days are Monday-Friday 5 days per week, 3-4 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

• Lasers and/or imaging is used to precisely deliver the daily radiation treatment.
• Expect to be on the treatment table less than 15 minutes.
• You will not feel any immediate effects.

Sometimes along with radiation to the breast, the high nodes in the neck (supraclavicular nodes) may be treated if there was cancer in the axilla

Logistics of Regional Nodal Radiation:

• Usually 25-33 daily treatments
• Treatment days are Monday-Friday 5 days per week, 5-6.5 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

Partial Breast Radiation Plan

Partial Breast Radiation Suitability

2023 Update

NSABP B39 Results:

Conclusion: For patients with early-stage breast cancer, our findings support whole-breast irradiation following lumpectomy; however, with an absolute difference of less than 1% in the 10-year cumulative incidence of IBTR, APBI might be an acceptable alternative for some women.

Logistics of Partial Breast Radiation:

• Option for select low risk patients and based on tumor location
• Usually 15 daily treatments
• Treatment days are Monday-Friday 5 days per week, 3 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

• Lasers and/or imaging is used to precisely deliver the daily radiation treatment.
• Expect to be on the treatment table less than 15 minutes.
• You will not feel any immediate effects.

Generally the side effects of breast radiation do not become noticeable until after about 10 to 15 treatments, and then become somewhat more noticeable through the rest of the treatment. The most common side effects:

• skin irritation - the skin that is radiated gets red, itchy and may blister (like a sun burn) may lose hair in arm pit (biafine, prutect, myaderm, aquaphor, silvadene, triamcinalone, Radiaderm)
• breast or chest wall tenderness or mild pain
• tiredness or fatigue (some women feel a little light-headed)
• breast swelling or edema

Short Term Side Effects of Breast Radiation  

Radiation Dermatitis

Everyone is Different

Long Term Risks of Whole Breast Radiation

• Cosmetic changes to the breast (usually smaller, firmer, sometime darker than before radiation)
• Arm swelling or lymphedema risk is typically low when not treating lymph nodes (risk based on lymph node involvement/dissection and radiation target)
• Lung inflammation (pneumonitis) is 2% or less
• Risk of rib fracture is less than 2% usually caused by trauma
• Risk of causing a new cancer is less than 1%
• Cardiac injury is possible but low with modern techniques

Short Term Side Effects of Breast Radiation�“Radiation Dermatitis” (sunburn)

First Day Last Day

This usually peaks at the end of treatment and one week following, and heals within 3-4 weeks of treatment completion

Long Term Risks of Regional Nodal Radiation

• Cosmetic changes to the breast (usually smaller, firmer, sometime darker than before radiation)
• Arm swelling or lymphedema (risk based on lymph node involvement/dissection and radiation target)
• Lung inflammation (pneumonitis) is 5% or less
• Risk of rib fracture is less than 3% usually caused by trauma
• Risk of nerve damage (brachial plexopathy) < 1%
• Risk of causing a new cancer is less than 1%
• Cardiac injury is possible but low with modern techniques