3.4 Breast Cancer Treatment: A Multidisciplinary Team Approach

Slide 1
[Slide: Breast Cancer Treatment: A Multidisciplinary Team Approach]
I’m Lisa Spiegel, I’m the Clinical Director of the University of Florida Breast Center and I’m here to introduce you to a multi-disciplinary approach to breast cancer care.

Slide 2
[diagram of the multidisciplinary care team with multiple healthcare providers surrounding the patient]
Multidisciplinary approach is really when the treatment of a patient involves more than one provider and how those providers come together as a unified team to really personalize the treatment plan for our patients.

Slide 3
[diagram showing breast cancer treatment divided into local therapy (breast and lymph nodes) and systemic therapy (whole body)]
For treatment of cancers, we typically need not only control of the local problem, for breast cancer it would be the local problem in the breast tissue as well as the lymph nodes, but we need control also of the entire body to protect the body from spread of those cancer cells so that they don’t cause a problem somewhere else.

Slide 4
And so, when we talk at- about local control for breast cancer, the surgical oncologist or the breast surgeon, is essential in terms of removing the tumor and determining whether that tumor has spread to the lymph nodes. So, we not only operate on the breast tissue but we operate on the lymph nodes but what’s also important in terms of locally treating that cancer is sometimes the role for radiation therapy.
And so, our radiation oncology colleagues are essential to help prevent cancer coming back into not only the breast but the lymph nodes.
Some women need larger surgeries such as mastectomy. Some women need reforming the breast tissue when we save the breast and therefore, at times, the plastic and reconstructive surgeons are needed again to recreate or reshape or reform the breast tissue after surgical treatment.
The other thing that is needed when we evaluate our patients is not only the cancer they have but whether those patients are at risk for future breast cancer. And so, our geneticists, our genetic counselors, are important in women that we worry could be, could have a genetic link to their breast cancer and may place them at higher risk for future breast cancer. And so, our treatment will not only focus on what we need to do to cure the cancer they’re diagnosed with but maybe we need to also focus on what we need to do to prevent future breast cancer.
And then the physical therapists are important to help the overall quality of life of our breast cancer survivors to help the changes related to surgery and radiation on the breast itself as well as to help monitor and prevent the development of arm swelling or lymphedema.

Slide 5
[slide title: systemic therapy]
Again, to cure, we need to protect the body and that’s where our medical oncologists come into play in terms of providing patients with individualized therapies to protect the body from their cancer spreading.

Slide 6
[diagram of the multidisciplinary care team with multiple healthcare providers surrounding the patient, repeated for emphasis]
And so, as you can see, all members of the team are crucial, and therefore we focus really on a multidisciplinary team approach with the patient in the center.

Slide 7
[mammogram images showing from two different angles a marked area in the breast tissue, indicating possible cancer]
I will take you through a patient of mine, Mrs. Y, who is a 65-year-old woman who is diagnosed with a screen-detected, or mammogram-detected, breast cancer. This is how we hope all women are diagnosed: women don’t have symptoms, they undergo their annual mammogram, and we find a distortion in the breast as you can see here, annotated here.

Slide 8
[ultrasound image showing a suspicious shadowing area in breast tissue]
You see an ultrasound that was performed that shows suspicious shadowing,

Slide 9
[diagram of the multidisciplinary care team, though with only the radiologist and patient shown]
And this is where this patient comes into the system,

Slide 10
through radiology whose role is for diagnostic imaging to detect and also to evaluate the extent of disease. Their job also is to get a diagnosis to do a biopsy, an image-guided biopsy to diagnose, and at times we need staging, additional imaging, to determine whether the cancer has spread.

Slide 11
[MRI image of both breasts with a circle over the left breast indicating the tumor; ultrasound image of a biopsy, with a circle to indicate the tumor]
Mrs. Y underwent an MRI which showed, looked at both breasts and showed a single area of disease in the left breast. She was recommended for an ultrasound-guided biopsy,

Slide 12
[diagram of the multidisciplinary care team, though with only the radiologist, pathologist, and patient shown]
And that tissue went to pathology. Our breast pathologists then evaluate the tissue to look at identification, origin of tissue, biology of tissue, look at the tumor markers to understand why this tumor is growing, such as hormones estrogen and progesterone or cell signaling proteins such as Her 2 Neu.

Slide 13
[image of cells under a microscope]
Mrs. Y had a very common cancer, an invasive ductal carcinoma, that was a grade one, good biology. Her tumor marker showed that the tumor responded or grew related to estrogen and progesterone in her body and that the cell signaling marker Her 2 Neu was not overexpressed, overall showing that she had a very good biology and less aggressive breast cancer.

Slide 14
[diagram of the multidisciplinary care team, though with only the radiologist, pathologist, breast surgeon, and patient shown]
At that point, she enters in to see the breast surgeon. We are there to assess the overall patient. We look at age, we look at overall general health, other comorbidities, we look at risk of future breast cancer through family history, and we also investigate a patient’s interest in treatment. We assess extent of disease, we look at the need for reconstruction in terms of recreation or reformation of the breast tissue, we think about timing of treatment modalities, and at that consultation, we develop an initial treatment plan.

Slide 15
[side-by-side illustrations of breast surgery treatment options, mastectomy vs incision]
In terms of the breast, we need to decide again how much disease is in the breast, can we save the breast safely, do we need to remove the breast, can we- do we need to remove all of the skin, can we save some of the skin, can we save all of the skin through a nipple-sparing mastectomy.

Slide 16
[images showing lymph nodes in the breast area relevant to cancer spread and surgical evaluation]
What do we do with the lymph nodes? Can we sample the lymph nodes or do we have to remove all the lymph nodes?

Slide 17
[diagram showing the typical sequence of breast cancer diagnosis, surgery, and adjuvant therapy such as chemotherapy, though this can occur in a different order]
We also look at timing. Traditional treatment is a diagnosis followed by surgery but some women need medicine prior to surgery. We think about timing.

Slide 18
[diagram of the multidisciplinary care team, though with only the radiologist, pathologist, breast surgeon, and patient shown, repeated for emphasis; diagram showing an individualized breast cancer treatment plan including diagnosis, staging, tumor markers, and treatment options such as surgery (breast-conserving or mastectomy) and systemic therapies like hormone therapy, chemotherapy, and targeted therapy]
And again, we develop an initial personalized treatment plan.

Slide 19
[original diagram of the full multidisciplinary care team with multiple healthcare providers surrounding the patient]
At that point, we refer to our colleagues.

Slide 20
[image showing health care professionals meeting in front of an MRI of breast tissue]
And we meet at a tumor board, a multi-disciplinary tumor conference, where we discuss each individual patient and come up with unified treatment options for each patient that is seen at UF Health. We review imaging- radiology reviews our imaging for us- pathology presents the pathology, and we come up with a unified treatment plan. We evaluate whether they’re candidates for clinical trials, whether genetics needs to be performed, if it hasn’t already, and we come up with a plan.

Slide 21
Mrs. Y underwent evaluation and, again, we noted that there was a single site of disease in the breast with a good overall biology. She had a family history which led to genetic testing. That genetic testing was negative for any pathogenic mutations and therefore her risk of future breast cancer was low. She went on to undergo breast conservation and, due to the good biology and single site of disease as well as overall age, she was a candidate for partial breast radiation, for which we use intraoperative radiation. Our radiation colleagues, my radiation colleagues, join me in the operating room. After the tumor is removed they then proceed with radiation during surgery, a one-time dose.

Slide 22
[illustration depicting a mammogram being performed]
Mrs. Y did wonderful- she’s following up with medical oncology to finalize the medical therapy she will need to prevent distant spread. She will follow up with physical therapy for any changes in the breast tissue as well as surveillance and prevention of lymphedema. And she will undergo active cancer surveillance with our team for five years.

Slide 23
[original diagram of the full multidisciplinary care team with multiple healthcare providers surrounding the patient, repeated for emphasis]
So, as you can see, cancer treatment, and as you see here with breast cancer treatment, is really a team approach to personalize care for each individual patient and this is what we call a multidisciplinary team approach to cancer care.