Final Ppt

Breast Cancer and Strategic Treatment

C.

Presented by: Komal Padhariya (T.Y.B.Pharm) Guided by: Mrs. Sugandha

Anatomy of breast Breast profile: A Ducts B Lobules C Dilated section of duct to hold milk D Nipple E Fat F Pectoralis major muscle G Chest wall/rib cage  Enlargement: A Normal duct cells B Basement membrane C Lumen (center of duct) 

Interior of breast 

The breast is composed of glandular and adipose tissue in varying proportions. The glandular tissue consists of 15–20 lobes containing numerous lobules, linked by ductules. The latter combine to form the lactiferous ducts

Blood supply to breast

Anatomy of the breast, showing lymph nodes  Each

breast also has blood vessels and lymph vessels. Lymph vessels lead to organs called lymph nodes. Lymph node filters substances in lymph and helps fight infection and

Breast cancer:  Breast

cancer is a disease in which malig  Age and health history can affect the risk of developing breast cancer.  Breast cancer is sometimes caused by inherited gene mutations (changes).  Certain factors affect prognosis (chance of recovery) and treatment options.

TYPES OF BREAST CANCER BREAST CANCER

NON INVASIVE & INVASIVE DCIS & LCIS

NON INVASIVE CELL GROWTH

VASCULAR & LYMPHATIC INVASION

1. DUCTAL CARCINOMA INSITU

2. LOBULAR CARCINOMA INSITU

1. SOLID

2. CRIBIFORM

3. INVASIVE DUCTAL CARCINOMA

4. INVASIVE LOBULAR CARCINOMA

3. PAPILLARY

4. COMEDO

NON INVASIVE & INVASIVE DCIS & LCIS Ductal Carcinoma in situ (DCIS)

Lobular Carcinoma in situ (LCIS)

A normal duct cells B ductal cancer A normal lobular cells cells B lobular cancer C basement cells membrane D lumen (center of C basement membrane duct)

Invasive Ductal Carcinoma (IDC)

A normal duct cells B ductal cancer cells breaking through the basement membrane

Invasive Lobular Carcinoma (ILC)

A normal cells B lobular cancer cells breaking through the basement membrane C basement

NON INVASIVE CELL GROWTH Solid

Cribiform

Papillary

Comedo

A living cancer cells A cancer cells A cancer cells A cancer cells B dying cancer cells B basement B basement membrane B basement C cell debris membrane C lumen (center of duct) membrane (necrosis) C lumen D basement (center of duct) membrane

Symptoms of breast cancer:           

Breast lump Lump or mass in the armpit A discharge from the nipple area – any bleeding or weeping Hardening of the skin in the nipple area Inversion of the nipple – turning inward or at an unusual angle Change in the sensation of the nipple Breast pain Weight loss Bone pain Breast enlargement only on one side Changes in the areola

RISK FACTORS OF BREAST CANCER There are two categories of risk factors for breast cancerthose we have control over (modifiable) and those we do not (non-modifiable) BEYOND YOUR CONTROL      

Gender Age Genetics Race Family History Late pregnancies

WITHIN YOUR CONTROL SMOKING  ALCOHOL  Radiation Exposure  Lifestyle 

Diagnosis of breast cancer: Breast self-exam  Breast physical exam, done by a doctor  Mammography 

Tests that examine the breasts are used to detect (find) and diagnose breast cancer.  Mammogram  Biopsy • Excisional biopsy •

Incisional biopsy

•

Core biopsy Needle biopsy Estrogen & progesterone receptor test

• •

STAGES OF BREAST CANCER Staging is the process physicians use to asses the size and location of patients cancer  To stage cancer, cancer are designated the letter T(Tumor size),N(Palpable nodes) and M(metastatis) 

Numerical Stages of Breast Cancer The stage of a breast cancer describes its size and the extent to which it. has spread. The staging system ranges from Stage 0 to Stage IV Staging Breast Cancer

Stage

Tumor Size

Lymph Node Involvement

Metastasis (Spread)

I II III IV

Less than 2 cm Between 2-5 cm More than 5 cm Not applicable

No No or in same side of breast Yes, on same side of breast Not applicable

No No No Yes

Stage

Definition

Stage 0

Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue

Stage I

Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear)

Stage II

The tumor is over 2 centimeters but no larger than 5 centimeters Or There is spread to the lymph nodes under the arm Also called locally advanced cancer. The tumor is more than 5 centimeters across Or The cancer is extensive in the underarm lymph nodes Or It has spread to other lymph nodes or tissues near the breast The cancer has spread—or metastasized—to

Stage III (includes substages IIIA & IIIB)

Stage IV

other parts of the body.

Additional staging information:  Early

stage: Stage 0 Stage I Stage II  Later stage: Stage II if there are many lymph nodes involved Stage III (IIIA, IIIB)  Advanced stage: Stage IV

Strategic treatment of breast cancer: Four types of standard treatment are used: Surgery Radiation therapy Chemotherapy Hormone therapy  New types of treatment Sentinel lymph node biopsy followed by surgery High-dose chemotherapy with stem cell transplant Monoclonal antibodies as adjuvant therapy 

Surgery 

Breast-conserving surgery



Lumpectomy Partial mastectomy



Breast-conserving surgery. Dotted lines show area containing the tumor that is removed and some of the lymph nodes that may be removed.

Other types of surgery include the following: 





Total mastectomy: Total mastectomy. Dotted line shows entire breast is removed. Some lymph nodes under the arm may also be removed. Modified radical mastectomy : Modified radical mastectomy. Dotted line shows entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed. Radical mastectomy:

Radiation therapy

  Woman in position for radiation treatment, from the front. Middle radiation beam is shown. A Bright yellow: breast being treated B Light yellow: beam in air, not touching woman C Opening of the linear accelerator D Arm holder supports woman's right arm  Woman in position for radiation treatment, from the side. Side radiation treatment beam is shown A Bright yellow: breast being treated B Light yellow: beam in air, not touching woman C Opening of the linear accelerator D Arm holder  Cross-sectional view of a woman receiving radiation to the breast area A Middle radiation beam B Side radiation beam C Bright yellow: place where radiation is given to the breast D Rib cage/chest wal lE Heart F Lungs G Backbone H Sternum/breast bone

Chemotherapy  Systemic

chemotherapy  Regional chemotherapy  Classes of Drugs:  Alkylators  Antimetabolites  Antibiotics  Antimiotic agents  Antimicrotubule

Chemotherapy combinations for non-metastatic breast cancer: 

  



AC ± T – Adriamycin (chemical name: doxorubicin) with cyclophosphamide (brand name: Cytoxan), with or without Taxol (chemical name: paclitaxel) or Taxotere (chemical name: docetaxol) CMF – cyclophosphamide, methotrexate, and fluorouracil ("5-FU" or 5-fluorouracil) CAF – cyclophosphamide, Adriamycin, and fluorouracil ("5-FU" or 5-fluorouracil) CEF – cyclophosphamide, Epirubicin (similar to Adriamycin), and fluorouracil ("5-FU" or 5fluorouracil) FAC – fluorouracil ("5-FU" or 5-fluorouracil), Adriamycin, and cyclophosphamide.

Hormone therapy 

Role of estrogen



Selective estrogenreceptor modulator (SERM) eg.Tamoxifen, Raloxifene, Toremifene

 Aromatase inhibitors • Arimidex • Aromasin • Femara  The only estrogenreceptor down regulator (ERD) Eg. Faslodex  Ovarian shutdown and removal

Side effects  Side

Effects Common to All Treatments:  Mood swings  Depression  Weight gain  Hot flashes  Vaginal dryness  Bloating  Early start of menopause (may be reversed)  "Flare reaction" or burning pain in bones (metastatic cancer only)

New types of treatment are being tested in clinical trials.  Sentinel

lymph node biopsy followed by surgery

•High-dose chemotherapy with stem cell transplant •Monoclonal antibodies as adjuvant therapy •Herceptin (chemical name: trastuzumab) is a very effective treatment against HER2-positive breast cancer in women with stage II, III, and IV disease (medium to large cancers or cancers with lymph nodes involved or metastatic disease.

HOW HERCEPTIN WORKS ? 1. BLOCKING OF THE TUMOR CELL GROWTH

SYSTEM

3. WORKING WITH CHEMOTHERAPY

2.SIGNALING OF THE IMMUNE

MECHANISM OF ACTION

Two tests are used to figure out if the cancer is likely to respond to Herceptin  

4.   

FISH (Fluorescence In Situ Hybridization) IHC (ImmunoHistoChemistry) FISH (Fluorescence In Situ Hybridization) Tests shows how many copies of HER 2 gene are in tumor cells Gives scores of either “positive” or “negative” If tumor “FISH positive” it will probably respond well to herceptin HER 2 amplification by single color FISH (red signals)

2. IHC (Immuno Histo Chemistry) • • • • • •

Test used to see if a tumor has too much of the HER 2 receptor protein on the surface of the cancer cells Gives a score of 0 to 3+ that indicates the amount of HER 2 receptor protein in the tumors If the tumor scores 0 to 1+ called “HER 2 negative”. If the tumor scores 2+ or 3+ called “HER 2 positive” Women with IHC positive respond favourably to herceptin Drug is not considered effective for tumors with IHC scores of 0and 1+

HER 2 overexpression (3+) shown by IHC

DOSAGE 

The dose is calculated by the weight of the patient



4mg/kg on the first day then 2mg/kg once a week .



Convert patient weight in to kg – 2.2 pounds=1kg . patients weight in pounds/2.2 = patient weight in kg



Insert patient weight in kg in to dosage equation using either 4 or 2 mg/kg as multiplier

FORMULA : patient weight in kg x = Herceptin reconstituted solution

ml of

ADMINISTRATION      

Given intravenously Given once a week or once every three weeks 4mg/kg loading dose administered over a 90 min infusion 2 mg/kg maintaince dose administered as a 30 min infusion DO NOT ADMINISTER as IV PUSH OR BOLUS Herceptin should not mixed or diluted with other drugs

SIDE EFFECTS OF HERCEPTIN

EARLY EFFECTS     

Fever and sweating Chills Skin flushing – redness Discomfort in the throat Difficulty in breathing

ONGOING EFFECTS     

Weakness , tiredness Headache Sore eyes Joint pain Diarrhea

LATE SIDE EFFECTS   

Heart problems Allergic like reactions Lung reactions

HERCEPTIN AND CHEMOTHERAPY  Herceptin

is often given in combination with other cancer drugs.  Some of the chemotherapy drugs that has been given with Herceptin includes  Taxol  Navelbine  Xeloda  Paraplatin  Chemotherapy drugs are given intravenously on the same weekly schedule as Herceptin  Studies revealed that , women with metastatic disease got better results when they took Herceptin with chemotherapy drugs

CONCLUSION: A survey says that every one in 875 women and every one in 10,000 men suffer from breast cancer worldwide. In many cases it is found as small tumor while in some the cancer spreads which could be fatal.  Early detection can help us to avoid serious damages caused by proliferation. This can be possible by self examination and with the help of the physician. 

The treatments for curing breast cancer are very expensive so spending “5 minutes for self examination OR 5 weeks in hospital” The choice is yours!!!

THANK YOU