Sentinel node with preop chemotherapy
Aug 2008 Shrenk et al Am J Surg: if SN negative before chemotherapy, may forego axillary dissection after chemo. micrometSN - not enough patients to know; macrometSN - the axilla is still positive after chemo - should have an ALND.
Doxorubicin
mechanism of action: Doxorubicin (INN, pronounced /ˌdɒksəˈruːbəsɪn/; trade name Adriamycin; also known as hydroxydaunorubicin) is a drug used in cancer chemotherapy. It is an anthracycline antibiotic, closely related to the natural product daunomycin, and like all anthracyclines it intercalates DNA. It is commonly used in the treatment of a wide range of cancers, including hematological malignancies, many types of carcinoma, and soft tissue sarcomas.
Cytoxan / Cyclophosphamide
Mechanism of action: Cyclophosphamide (the generic name for Endoxan, Cytoxan, Neosar, Procytox, Revimmune), also known as cytophosphane, is a nitrogen mustard alkylating agent, from the oxazophorines group. It is used to treat various types of cancer and some autoimmune disorders. It is a "prodrug"; it is converted in the liver to active forms that have chemotherapeutic activity.
Taxotere / Docetaxel
breast, lung, prostate, head/neck, gastric
brand: taxotere
generic name: docetaxel
given IV q 3 weeks; steroid pretreatment.
Should Taxotere plus Cytoxan be the new gold standard for breast cancer treatment? The results of a Phase III clinical trial, published in the Journal of Clinical Oncology, concluded that Taxotere (docetaxel) plus Cytoxan (cyclophosphamide) resulted in better cancer free survival than the treatment combination of Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide).
The results of a Phase III clinical trial, published in the Journal of Clinical Oncology, concluded that Taxotere (docetaxel) plus Cytoxan (cyclophosphamide) resulted in better cancer free survival than the treatment combination of Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide).
Adriamycin and Cytoxan, referred to as the AC chemotherapy regime, has been the gold standard for adjuvant therapy for those patients diagnosed with early stage breast cancer. This study was conducted on more than 1000 women who had Stage I to Stage III disease. Half of the women were given the AC regime and the other half given the Taxotere/Cytoxan (TC) regime.
The results of the study showed that cancer free survival was 86 percent for those treated with TC an 80 percent among women treated with AC. Overall survival was 90 percent among women treated with TC and 87 percent among women treated with AC. Nausea and vomiting were more common among women treated with AC. Muscle and joint pain, edema, and low white blood cell counts accompanied by fever were more common among patients treated with TC.
brand: taxotere
generic name: docetaxel
given IV q 3 weeks; steroid pretreatment.
Should Taxotere plus Cytoxan be the new gold standard for breast cancer treatment? The results of a Phase III clinical trial, published in the Journal of Clinical Oncology, concluded that Taxotere (docetaxel) plus Cytoxan (cyclophosphamide) resulted in better cancer free survival than the treatment combination of Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide).
The results of a Phase III clinical trial, published in the Journal of Clinical Oncology, concluded that Taxotere (docetaxel) plus Cytoxan (cyclophosphamide) resulted in better cancer free survival than the treatment combination of Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide).
Adriamycin and Cytoxan, referred to as the AC chemotherapy regime, has been the gold standard for adjuvant therapy for those patients diagnosed with early stage breast cancer. This study was conducted on more than 1000 women who had Stage I to Stage III disease. Half of the women were given the AC regime and the other half given the Taxotere/Cytoxan (TC) regime.
The results of the study showed that cancer free survival was 86 percent for those treated with TC an 80 percent among women treated with AC. Overall survival was 90 percent among women treated with TC and 87 percent among women treated with AC. Nausea and vomiting were more common among women treated with AC. Muscle and joint pain, edema, and low white blood cell counts accompanied by fever were more common among patients treated with TC.
Claus Model for Breast Cancer Risk Assessment
Another breast cancer risk assessment model, the Claus Model, considers breast cancer diagnoses in first- and second-degree relatives in both the paternal and maternal family history. Like the Gail Model, however, the Claus model does not consider other cancers which may signal a hereditary component, such as ovarian cancer and male breast cancer.
Gail Model for Breast Cancer Risk Assessment
When to the use the gail model: Using the Gail Model to Help Your Patients
The Gail model is a nationally accepted epidemiologic model for identifying women at higher inherited risk for breast and ovarian cancer based on family history.
What is the Gail Model?
The Gail model...
was developed by Gail and colleagues at the National Cancer Institute;
is widely used to quantify an individual woman's risk of developing breast cancer, usually for clinical counseling purposes or to determine eligibility for clinical trials;
allows one to estimate the likelihood that a woman of a given age with certain risk factors will develop breast cancer over a specified time interval;
is based on data from the Breast Cancer Detection and Demonstration Project, a mammography screening project involving over 280,000 women that was conducted between 1973 and 1980;
was developed by looking at a number of potential risk factors for breast cancer;
uses five significant predictors of a woman's lifetime breast cancer risk:
1. current age
2. age at menarche
3. number of breast biopsies
4. age at first live birth
5. number of first-degree relatives with breast cancer
How Are Risks Calculated With the Gail Model?
In order to use the model, the five pieces of information listed above must be known. The easiest way to use the Gail model is through an interactive computer program which asks the user to enter the necessary information and then immediately calculates the patient's cumulative breast cancer risk over the next 10, 20, and 30 years. The program, intended primarily for health-professional use, is available online as a Breast Cancer Risk Assessment Tool at the National Cancer Institute's web site.
Published tables and graphs by Gail et al. (1989) may also be used to manually calculate the relative risk and estimated cumulative probabilities of breast cancer for an individual woman. However, use of these tables and graphs is time-consuming and subject to error because of the hand calculations required than use of the computer program.
Gail MH, Brinton LA, Byar DP, et al: Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Cancer Inst 81:1879-86 (1989).
Benichou J, Gail MH, Mulvihill JJ: Graphs to estimate an individualized risk of breast cancer. J Clin Oncol 14:103-110 (1996).
What Does the Gail Model Tell Me?
Cumulative risks of breast cancer calculated by the Gail model may be used in a clinical setting to provide individualized information to women about their breast cancer risk. Using the Gail model, clinicians may:
identify women who are at increased risk;
discuss modified options for breast cancer screening, such as beginning mammography at a younger age or having more frequent clinical breast examinations;
provide reassurance to many women who had previously overestimated their risk of breast cancer.
What Are Its Limitations?
Studies that have attempted to validate the Gail model found that it over-predicts the risk of breast cancer among women age 35 to 61 who do not receive annual mammograms.
The overestimation is more marked in pre-menopausal women and in those with an extensive family history. The model...
was developed based on data from women receiving annual mammograms, and thus its most appropriate use is among this population of women, and
does not take into account the ages at which affected relatives were diagnosed with breast cancer, nor does it consider a history of breast cancer on the father's side of the family (because only first-degree relative are considered).
Thus, women who have a history of close (first-, second-, and third-degree) relatives with early-onset breast cancer may benefit from the use of other models, such as the Claus model.
Risk-assessment models are not appropriate for women with family histories that are strongly suggestive of an inherited cancer syndrome or in families in which a specific genetic mutation in a gene such as BRCA1 or BRCA2 has been identified. Instead, such women should be counseled based on their position in the family pedigree...and the chance that they inherited the mutation that has been identified or is likely to exist in their family.
Related Information
Breast Cancer
Cancer Risk Counseling
The Claus Model
This page is part of The Genetics
----------
Link to online calculator:
Before using the tool, please note the following:
The Breast Cancer Risk Assessment Tool was designed for use by health professionals. If you are not a health professional, you are encouraged to discuss the results and your personal risk of breast cancer with your doctor.
The tool should not be used to calculate breast cancer risk for women who have already had a diagnosis of breast cancer, lobular carcinoma in situ (LCIS), or ductal carcinoma in situ (DCIS).
The BCRA risk calculator may be updated periodically as new data or research becomes available.
Although the tool has been used with success in clinics for women with strong family histories of breast cancer, more specific methods of estimating risk are appropriate for women known to have breast cancer-producing mutations in the BRCA1 or BRCA2 genes.
Other factors may also affect risk and are not accounted for by the tool. These factors include previous radiation therapy to the chest for the treatment of Hodgkin lymphoma or recent migration from a region with low breast cancer rates, such as rural China. The tool's risk calculations assume that a woman is screened for breast cancer as in the general U.S. population. A woman who does not have mammograms will have somewhat lower chances of a diagnosis of breast cancer.
For information to help your patients understand cancer risk visit http://understandingrisk.cancer.gov. This interactive Web site will help your patients make informed decisions about how to lower their risk.
The Gail model is a nationally accepted epidemiologic model for identifying women at higher inherited risk for breast and ovarian cancer based on family history.
What is the Gail Model?
The Gail model...
was developed by Gail and colleagues at the National Cancer Institute;
is widely used to quantify an individual woman's risk of developing breast cancer, usually for clinical counseling purposes or to determine eligibility for clinical trials;
allows one to estimate the likelihood that a woman of a given age with certain risk factors will develop breast cancer over a specified time interval;
is based on data from the Breast Cancer Detection and Demonstration Project, a mammography screening project involving over 280,000 women that was conducted between 1973 and 1980;
was developed by looking at a number of potential risk factors for breast cancer;
uses five significant predictors of a woman's lifetime breast cancer risk:
1. current age
2. age at menarche
3. number of breast biopsies
4. age at first live birth
5. number of first-degree relatives with breast cancer
How Are Risks Calculated With the Gail Model?
In order to use the model, the five pieces of information listed above must be known. The easiest way to use the Gail model is through an interactive computer program which asks the user to enter the necessary information and then immediately calculates the patient's cumulative breast cancer risk over the next 10, 20, and 30 years. The program, intended primarily for health-professional use, is available online as a Breast Cancer Risk Assessment Tool at the National Cancer Institute's web site.
Published tables and graphs by Gail et al. (1989) may also be used to manually calculate the relative risk and estimated cumulative probabilities of breast cancer for an individual woman. However, use of these tables and graphs is time-consuming and subject to error because of the hand calculations required than use of the computer program.
Gail MH, Brinton LA, Byar DP, et al: Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Cancer Inst 81:1879-86 (1989).
Benichou J, Gail MH, Mulvihill JJ: Graphs to estimate an individualized risk of breast cancer. J Clin Oncol 14:103-110 (1996).
What Does the Gail Model Tell Me?
Cumulative risks of breast cancer calculated by the Gail model may be used in a clinical setting to provide individualized information to women about their breast cancer risk. Using the Gail model, clinicians may:
identify women who are at increased risk;
discuss modified options for breast cancer screening, such as beginning mammography at a younger age or having more frequent clinical breast examinations;
provide reassurance to many women who had previously overestimated their risk of breast cancer.
What Are Its Limitations?
Studies that have attempted to validate the Gail model found that it over-predicts the risk of breast cancer among women age 35 to 61 who do not receive annual mammograms.
The overestimation is more marked in pre-menopausal women and in those with an extensive family history. The model...
was developed based on data from women receiving annual mammograms, and thus its most appropriate use is among this population of women, and
does not take into account the ages at which affected relatives were diagnosed with breast cancer, nor does it consider a history of breast cancer on the father's side of the family (because only first-degree relative are considered).
Thus, women who have a history of close (first-, second-, and third-degree) relatives with early-onset breast cancer may benefit from the use of other models, such as the Claus model.
Risk-assessment models are not appropriate for women with family histories that are strongly suggestive of an inherited cancer syndrome or in families in which a specific genetic mutation in a gene such as BRCA1 or BRCA2 has been identified. Instead, such women should be counseled based on their position in the family pedigree...and the chance that they inherited the mutation that has been identified or is likely to exist in their family.
Related Information
Breast Cancer
Cancer Risk Counseling
The Claus Model
This page is part of The Genetics
----------
Link to online calculator:
Before using the tool, please note the following:
The Breast Cancer Risk Assessment Tool was designed for use by health professionals. If you are not a health professional, you are encouraged to discuss the results and your personal risk of breast cancer with your doctor.
The tool should not be used to calculate breast cancer risk for women who have already had a diagnosis of breast cancer, lobular carcinoma in situ (LCIS), or ductal carcinoma in situ (DCIS).
The BCRA risk calculator may be updated periodically as new data or research becomes available.
Although the tool has been used with success in clinics for women with strong family histories of breast cancer, more specific methods of estimating risk are appropriate for women known to have breast cancer-producing mutations in the BRCA1 or BRCA2 genes.
Other factors may also affect risk and are not accounted for by the tool. These factors include previous radiation therapy to the chest for the treatment of Hodgkin lymphoma or recent migration from a region with low breast cancer rates, such as rural China. The tool's risk calculations assume that a woman is screened for breast cancer as in the general U.S. population. A woman who does not have mammograms will have somewhat lower chances of a diagnosis of breast cancer.
For information to help your patients understand cancer risk visit http://understandingrisk.cancer.gov. This interactive Web site will help your patients make informed decisions about how to lower their risk.
Pregnancy Associated Breast Cancer
University of Texas M. D. Anderson Cancer Center: However, the largest single-institution study to look at pregnant breast cancer patients finds that women with Pregnancy Associated Breast Cancer (PABC), are more likely to be diagnosed later with advanced stages of the disease and, thus, have necessary treatment delayed.
It's estimated that up to 3.8 percent of pregnancies are complicated by breast cancer, and approximately 10 percent of breast cancer patients under age 40 develop the disease during pregnancy, said the researchers.
"Because we see care for large volume of patients who are young, as well as those who are young and pregnant, we wanted to see if there was something additive going on that is attributed to pregnancy, or if the response to treatment and behavior of the disease is a phenomenon of young age itself," said Perkins, the study's senior author.
M. D. Anderson has a long history of being at the forefront of treating pregnant women for breast cancer. In 1992, Richard Theriault, D.O., professor in the Department of Breast Medical Oncology, opened the first protocol examining a chemotherapeutic regimen for the management of these patients. He later published seminal studies proving that the regimen was safe for both pregnant mother and unborn child; it has since been adopted as the standard of care. M. D. Anderson has the largest active registry in the world following the health of pregnant breast cancer patients and their children.
Journal reference:
Beth M. Beadle, Wendy A. Woodward, Lavinia P. Middleton, Welela Tereffe, Eric A. Strom, Jennifer K. Litton, Funda Meric-Bernstam, Richard L. Theriault, Thomas A. Buchholz, and George H. Perkins. The impact of pregnancy on breast cancer outcomes in women %u226435 years old. Cancer, Online: February 09, 2009; Print Issue Date: March 15, 2009. DOI: 10.1002/cncr.24165
------------
US News and World Report has 5 questions you should ask related to Pregnancy Associated Breast Cancer
It's estimated that up to 3.8 percent of pregnancies are complicated by breast cancer, and approximately 10 percent of breast cancer patients under age 40 develop the disease during pregnancy, said the researchers.
"Because we see care for large volume of patients who are young, as well as those who are young and pregnant, we wanted to see if there was something additive going on that is attributed to pregnancy, or if the response to treatment and behavior of the disease is a phenomenon of young age itself," said Perkins, the study's senior author.
M. D. Anderson has a long history of being at the forefront of treating pregnant women for breast cancer. In 1992, Richard Theriault, D.O., professor in the Department of Breast Medical Oncology, opened the first protocol examining a chemotherapeutic regimen for the management of these patients. He later published seminal studies proving that the regimen was safe for both pregnant mother and unborn child; it has since been adopted as the standard of care. M. D. Anderson has the largest active registry in the world following the health of pregnant breast cancer patients and their children.
Journal reference:
Beth M. Beadle, Wendy A. Woodward, Lavinia P. Middleton, Welela Tereffe, Eric A. Strom, Jennifer K. Litton, Funda Meric-Bernstam, Richard L. Theriault, Thomas A. Buchholz, and George H. Perkins. The impact of pregnancy on breast cancer outcomes in women %u226435 years old. Cancer, Online: February 09, 2009; Print Issue Date: March 15, 2009. DOI: 10.1002/cncr.24165
------------
US News and World Report has 5 questions you should ask related to Pregnancy Associated Breast Cancer
Micrometastases in Breast Cancer
February 1, 2007
Oncology News International. Vol. 16 No. 2
Micrometastases are defined as lesions 0.2 to 2.0 mm and are detected by step-sectioning H—E staining, while ITCs (sub/nanomicrometastases) are less than 0.2 mm and are usually found only by immunohistochemical staining (IHC).
In another study from the John Wayne Cancer Center, 5-year disease-free survival was approximately 98% for patients with either micrometastases or IHC-negative nodes.
Why bother with this issue? he asked. "At most, with chemotherapy these patients would gain a 1% to 2% improvement in survival, and most of them receive adjuvant therapy anyway [based on other factors]," he said. Prognostic assessments might be better derived from other tools, he said, such as the 70-gene prognostic gene array (Mammaprint) developed at his institution, which can distinguish risk profiles even in patients with a single positive node.
• With micrometastases (0.2 to 2.0 mm), a lymph node dissection is generally advised. Patients with negative non-sentinel nodes should be considered node negative and treated with adjuvant therapy based on the primary tumor characteristics. Positive non-sentinel nodes are an adverse sign, and patients should be treated accordingly. Isolated tumor cells (less than 0.2 mm) have no reasonable clinical relevance, at this point, and these patients should be considered node negative, he said.
When Is There Cause for Concern?
FRANKIE ANN HOLMES, MD—"Regarding micrometastases, one of the things we are continuing to see is these delayed relapses," Dr. Holmes, co-director, Breast Cancer Research, US Oncology, Houston, told ONI. "In order to study and understand this phenomenon, I agree with Dr. Alberti [abstract 25] in that we probably need a longer time frame." She also said that it is important "to get inside these tumor cells and learn which genes are predicting relapse."
Dr. Holmes' bias regarding the significance of micrometastases and isolated tumor cells (ITCs) is this: "If the tumor has 'eloped' to another site, it tells me that this tumor means business, and we should be concerned." Fitting this picture would be a patient with micrometastases and ITCs with an ER/PR-negative grade 3 tumor. "This is a nasty tumor," she said. "Many times, you can look at the primary tumor and by its characteristics, you know that cells in the nodes are a moot point. You already know how to treat the patient."
When patients with otherwise good prognostic factors have nanometas-tases, there may be less cause for concern, she said. "To give us more information, we can use the OncotypeDx test for node-negative patients and patients with ITCs, who are technically node negative," Dr. Holmes said. "But micrometastases are classified as technically node positive, and OncotypeDx has not been tested for node-positive patients. We rely on judgment, Adjuvant!, and established guidelines, and treat them as node positive."
Netherlands study: does not recommend treatment -
Oxford Journals Medicine Annals of Oncology Volume 20, Number 1 Pp. 41-48
Prognostic value of micrometastases in sentinel lymph nodes of patients with breast carcinoma: a cohort study
P. D. Gobardhan4, S. G. Elias1, E. V. E. Madsen4, V. Bongers2, H. J. M. Ruitenberg3, C. I. Perre4 and T. van Dalen4,*
1 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht
2 Department of Nuclear Medicine, Diakonessenhuis Utrecht
3 Department of Pathology, Diakonessenhuis Utrecht, The Netherlands
4 Department of Surgery, Diakonessenhuis Utrecht
* Correspondence to: Dr T. van Dalen, Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat 1, 3582 KE Utrecht, The Netherlands. Tel: +31-30-2566225; Fax: +31-30-2566210; E-mail: tvdalen@diakhuis.nl
-------------
interestingly - here is another take on the findings - they conclude that the recurrence rate is increased with micromets by 10% and the magazine is sponsored by Pfizer.
Oncology News International. Vol. 16 No. 2
Micrometastases are defined as lesions 0.2 to 2.0 mm and are detected by step-sectioning H—E staining, while ITCs (sub/nanomicrometastases) are less than 0.2 mm and are usually found only by immunohistochemical staining (IHC).
In another study from the John Wayne Cancer Center, 5-year disease-free survival was approximately 98% for patients with either micrometastases or IHC-negative nodes.
Why bother with this issue? he asked. "At most, with chemotherapy these patients would gain a 1% to 2% improvement in survival, and most of them receive adjuvant therapy anyway [based on other factors]," he said. Prognostic assessments might be better derived from other tools, he said, such as the 70-gene prognostic gene array (Mammaprint) developed at his institution, which can distinguish risk profiles even in patients with a single positive node.
• With micrometastases (0.2 to 2.0 mm), a lymph node dissection is generally advised. Patients with negative non-sentinel nodes should be considered node negative and treated with adjuvant therapy based on the primary tumor characteristics. Positive non-sentinel nodes are an adverse sign, and patients should be treated accordingly. Isolated tumor cells (less than 0.2 mm) have no reasonable clinical relevance, at this point, and these patients should be considered node negative, he said.
When Is There Cause for Concern?
FRANKIE ANN HOLMES, MD—"Regarding micrometastases, one of the things we are continuing to see is these delayed relapses," Dr. Holmes, co-director, Breast Cancer Research, US Oncology, Houston, told ONI. "In order to study and understand this phenomenon, I agree with Dr. Alberti [abstract 25] in that we probably need a longer time frame." She also said that it is important "to get inside these tumor cells and learn which genes are predicting relapse."
Dr. Holmes' bias regarding the significance of micrometastases and isolated tumor cells (ITCs) is this: "If the tumor has 'eloped' to another site, it tells me that this tumor means business, and we should be concerned." Fitting this picture would be a patient with micrometastases and ITCs with an ER/PR-negative grade 3 tumor. "This is a nasty tumor," she said. "Many times, you can look at the primary tumor and by its characteristics, you know that cells in the nodes are a moot point. You already know how to treat the patient."
When patients with otherwise good prognostic factors have nanometas-tases, there may be less cause for concern, she said. "To give us more information, we can use the OncotypeDx test for node-negative patients and patients with ITCs, who are technically node negative," Dr. Holmes said. "But micrometastases are classified as technically node positive, and OncotypeDx has not been tested for node-positive patients. We rely on judgment, Adjuvant!, and established guidelines, and treat them as node positive."
Netherlands study: does not recommend treatment -
Oxford Journals Medicine Annals of Oncology Volume 20, Number 1 Pp. 41-48
Prognostic value of micrometastases in sentinel lymph nodes of patients with breast carcinoma: a cohort study
P. D. Gobardhan4, S. G. Elias1, E. V. E. Madsen4, V. Bongers2, H. J. M. Ruitenberg3, C. I. Perre4 and T. van Dalen4,*
1 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht
2 Department of Nuclear Medicine, Diakonessenhuis Utrecht
3 Department of Pathology, Diakonessenhuis Utrecht, The Netherlands
4 Department of Surgery, Diakonessenhuis Utrecht
* Correspondence to: Dr T. van Dalen, Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat 1, 3582 KE Utrecht, The Netherlands. Tel: +31-30-2566225; Fax: +31-30-2566210; E-mail: tvdalen@diakhuis.nl
-------------
interestingly - here is another take on the findings - they conclude that the recurrence rate is increased with micromets by 10% and the magazine is sponsored by Pfizer.
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