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Dr. Hy Muss on Breast Cancer in Older Women: Population Trends by Age

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Dr. Hy Muss, medical oncologist and Director of the Geriatric Oncology Program at the University of North Carolina, Chapel Hill, is both a renowned expert in breast cancer and among the world’s leading luminaries on the important topic of cancer care in older patients.  Though many times it’s young celebrities with breast or other cancer who gather the attention of the media, in truth cancer is a disease that still disproportionately affects older people.  Much of the cancer in the real world of our oncology clinics is elderly patients, who are also understudied in our research relative to their importance as a population.

Dr. Muss was kind enough to sit down with our own very excellent Dr. Jared Weiss, also at UNC-Chapel Hill, to do a slide-based presentation of the leading important points on breast cancer in older women. Here’s the first part of that presentation, including video and audio versions of the podcast, along with the associated transcript and figures.

Muss Breast Ca in Older Women Pt 1 Pop Trends by Age Audio Podcast

Muss Breast Ca in Older Women Pt 1 Pop Trends by Age Transcript

Muss Breast Ca in Older Women Pt 1 Pop Trends by Age Figures

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Survivorship after breast cancer

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Survival statistics for women with breast cancer have improved dramatically in recent years, resulting in the majority of newly diagnosed breast cancer patients surviving more than 5 years after their diagnosis. In fact, in 2010, the American Cancer Society estimated that there are 2.5 million breast cancer survivors in the US.

This is obviously excellent news, but it makes it very important that patients and their primary care providers be able to recognize and treat any chronic (side effects occurring during and persisting after treatment) and late (side effects that appear after the end of therapy) consequences of cancer therapy. In 2006, the Office of Cancer Survivorship (OCS) was formed at the National Cancer Institute, reflecting an increased emphasis on the needs of a growing population of cancer survivors. Some of the most prominent issues facing breast cancer survivors include the following:

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OncoType Dx: Tumor Gene Profiling to Modify Our Treatment Recommendations

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In the past, oncologists were primarily concerned with whether a breast cancer was hormone receptor-positive (ER+) or negative and whether it overexpressed HER2 or not. And the vast majority of women with early stage breast cancer were given chemotherapy to try to prevent their breast cancer from coming back, regardless of hormone receptor results or lymph node status. Unfortunately, many of those women would likely have been cured without chemotherapy, but we didn’t have any reliable way to distinguish who needed chemotherapy and who did not.

The good news is that we really have come a long way in recent years in developing ways to make this distinction, spare many women the side effects of chemotherapy and truly personalize treatment decisions. This is very exciting, because more than half of the women in the U.S. diagnosed with breast cancer have ER+, lymph-node-negative cancer. New tests that are now available identify genetic or biological factors that drive each individual woman’s particular cancer, allowing their oncologists to personalize treatment in a way we were unable to do in the past. Multiple assays are commercially available to look at the genes in an individual cancer. In the US, Oncotype DX is the most commonly used.

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Radiation Therapy: A Core Component of Breast Conservation

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Radiation therapy plays an important part in the care of many breast cancer patients. The term breast conservation therapy (BCT) is a combination of breast conserving surgery (also referred to as lumpectomy) and radiation therapy. It is only in rare circumstances that breast conservation surgery is undertaken without planned radiotherapy to follow. For patients that undergo mastectomy instead of breast conservation surgery, radiation therapy may still play an important role, but it is not of universal benefit as it is after breast conservation surgery.

Many options exist for radiation therapy after lumpectomy. “Conventionally fractionated” whole breast irradiation remains the standard treatment in the United States and is the treatment received by most women after lumpectomy. “Conventionally fractionated radiation” refers to dividing the total radiation dose into small amounts which are delivered on a 5-treatment per week basis, for a total of five to six and a half weeks. The entire breast is treated for the majority of the treatment course. Near the end of the treatment, only the specific region of the breast which formerly contained the tumor is targeted, typically for the last 5 treatments; this more focused component of the treatment is referred to as a “radiation boost.”

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Inflammatory Breast Cancer: What is It, and Who Gets It?

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While inflammatory breast cancer (IBC) is a particularly aggressive disease, it is actually quite rare, representing less than 5% of all breast cancer cases diagnosed in the US. As a result, many patients and physicians are considerably less familiar with it than more common forms of breast cancer. Historically, the prognosis of IBC has been quite poor, with very low survival rates. However, with the advent of multimodality therapy (a strategy that includes chemotherapy, surgery, and radiation therapy in combination), survival rates have improved, although they still remain lower than other breast cancers.

IBC is characterized by the rapid appearance and worsening of redness, swelling, warmth and pain of the breast. The swelling is frequently associated with distention of the hair follicles leading to a peau d’orange or “orange peel” appearance of the breast. Images of IBC are available here. The characteristic red, swollen appearance of the breast is caused by tumor cells blocking the lymphatic channels in the involved area. In the majority of patients with IBC, no mass is palpable in the breast. As a result, the symptoms are often mistaken by patients and their physicians for non-cancerous conditions, such as infection, thereby delaying diagnosis. Also, there are variations in the presentation that can also result in a delay in diagnosis. For example, African-American and other darker-skinned women frequently have swelling and peau d’orange changes with minimal or no redness.

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