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Dr. Denise Yardley of the Sarah Cannon Research Institute discusses biopsy results and how they impact the treatment of breast cancer.

Q: Welcome to Understanding Cancer.  Today we’re speaking with Dr. Denise Yardley, the director of the breast cancer research program at the Sarah Cannon Research Institute in Nashville, Tennessee.  Welcome.

A: Thank you.

Q: When you’re thinking about the overall treatment plan, I think there’s also information that you can collect off the biopsy specimen that’s very relevant to the patient.  Could you walk us through what those tests are, and why they’re important?

A: They’re very important, and as I tell all patients, it gives us the first glimpse at what the abnormality is on the breast.  Now, the whole story really unfolds at the time of surgery, when we have both the lymph node sampling and exactly how much of an abnormality is present in the breast.  But just that initial biopsy confirms whether the abnormality, identified either by a physical exam or a mammogram, in fact is cancer.  We have many abnormalities in the breast that aren’t cancer, so that’s the most important, is to establish what that abnormality is under the microscope.

And then we have two different types of cancer, so the approaches are different on those as well, that the mammogram identifies or can be a lesion that the patient feels, and that’s either an invasive cancer, that’s a cancer that actually has the potential to spread to a lymph node or other parts of the body, or noninvasive cancer, which really ends up being more a surgical issue and doesn’t really require consideration of chemotherapy.

We also get a flavor of how aggressive, if it is a cancer, what it looks like under the microscope.  Is this a more aggressive tumor or is this a tumor that is associated with a little less aggressive behavior or a little less likelihood of spreading elsewhere?  It also tells us a little bit about what might be future treatments in the patient after surgery, such as the role of hormonal therapy relative to chemotherapy, and some of the new biologic agents.  So it gives us the first snapshot of possibilities.  But none of that is completed until after the surgery is…gives us the rest of the information and is performed.

Q: So as part of your initial evaluation, the patient has a biopsy confirmed breast cancer and these various tests have been done, and a lymph node evaluation has been done.  Are there any other tests that are used to evaluate whether the cancer has spread?

A: Typically, once surgery’s been completed and we have a sense of how much volume of disease, how big the tumor was on the breast, and if there were lymph nodes involved or not, the lymph node status, if patients are lymph node negative, puts them in the best prognosis group, because that’s the most important prognostic factor.

For lymph node positive patients, we typically undergo a full evaluation of assessing the sites that breast cancer may go to, and that typically is liver, lung or bone.  The likelihood of us detecting something by our scans is still very small because these are typically microscopic cells.  But we know if tumor cells have spread to a lymph node they’re at a higher chance of having gone somewhere else in the body.  But even using these screening tools, we typically don’t find evidence of disease.

Q: So once you’ve completed that part of the evaluation, the majority of patients that come to you are going to have early stage breast cancer, Stage I, II, or III?

A: Right.

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Q: So when someone has early stage breast cancer, how do you then generally explain what their treatment options are going to be?

A: What their…and that, I think, is the longest discussion with patients, to really get them a sense of what the recommendations are when you don’t have evidence of disease, but you’re really treating a risk.  And the first thing I typically do with patients is go through what the risk factors for breast cancer are after we have the surgical evaluation.  So the most important is the status of the lymph nodes.  That still remains the most important risk factor for breast cancer recurring sometime in their life.

So if their lymph nodes are negative, that already puts them in the most favorable prognostic group.  We typically, in the past, if you go back 30 and 40 years, spared those patients from any treatment, and we found that about 30% of those patients, unfortunately, did relapse, and so we look now at other factors to see, in those patients who relapse, does this particular node negative patient have some of those features.  And once the lymph nodes are negative, it’s tumor size, and so we look at the size of the tumor removed at surgery.

We look, again, at that level of aggressiveness, what grade did the pathologist look at under the microscope, was it more aggressive looking or a more indolent or well behaving tumor.  We look at those factors of the estrogen and progesterone receptor in her, too, trying to get a sense and feel for how high risk or low risk or what the likelihood is the patient falls on that 30% chance of disease coming back.  And then that really falls into treatment options.  Do we want to add treatment now following surgery, with either chemotherapy, hormonal therapy or both as a risk reduction.

For lymph node positive patients, the risk goes up substantially, and evidence of disease in one lymph node conveys about a 50% chance of recurrence, a 50% chance they’re cured with surgery only, and I try to stress that with patients.  We focus a lot on treatment, but still the option is that 50% of them require no additional therapy after surgery.  But for a risk of 50%, patients are much more willing, I think, to consider additional therapy, which may include chemotherapy or just hormonal therapy.

So when I meet with patients after all surgery is complete, we really go through all the findings of that surgery, and kind of put together a risk assessment of the likelihood that somewhere during the course of their life they may experience disease again, and then what the treatment options – hormonal, chemotherapy or both, or even Herceptin or some of our biologic therapies may offer in terms of risk reductions in reducing the chance that that patient will ever have to deal with breast cancer again.

Q: One question I get from patients sometimes is if I have a relatively low risk of the cancer returning, why don’t I just wait and treat it when it comes back?

A: And that’s a good question, and patients pose that.  And it’s interesting, ‘cause it’s not really a physician option, it’s a patient option.  And the issue becomes that at the early stage, right after surgery, that’s when our therapy has the greatest risk of impacting or benefiting the patient.  Once the disease comes back, it’s still very treatable, and I do emphasize that with patients, but not curable.

We have not been able to cure advanced or metastatic or Stage IV breast cancer.  We can treat them, and our treatments have kept patients, and the disease, really changing it now to a chronic disease.  But when we’re really looking to cure a patient and prevent them from ever having to experience that entity, those recommendations follow immediately after surgery and cannot follow when the disease comes back.

Q: So you’re really better off treating it aggressively the first time?

A: Aggressively upfront when the tumor burden is the smallest and there’s just maybe micro metastatic disease that you’re trying to remove from the patient.

Q: Well, Dr. Yardley, I’d like to thank you for your time today.  I think our viewers will find this session most informative, and we look forward to having you back.

A: Thank you.