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Assessing the Surgical Care of Breast Cancer

Assessing the Surgical Care of Breast Cancer

Clinical trials have shown that survival rates appear to be similar for patients with early-stage breast cancer who are treated with breast-conserving surgery and radiation or with mastectomy. “However, recent studies have indicated that the use of mastectomy is increasing, particularly bilateral mastectomy, among women in the United States with breast cancer,” says Allison W. Kurian, MD, MSc. Typically, bilateral mastectomy is considered both a treatment for the affected breast and a prevention measure for the contralateral breast. Bilateral mastectomy is increasingly being used to treat unilateral breast cancer despite the absence of evidence showing that it offers a survival benefit to the average woman with breast cancer. Bilateral mastectomy has been shown to be an effective secondary prevention strategy for high-risk women with BRCA1/2 mutations, but the procedure may also have detrimental effects. These include higher risks for complications, increased costs, and a negative impact on body image and sexual function. “We need a better understanding of the use of bilateral mastectomy and outcomes associated with its use to improve cancer care,” Dr. Kurian says. A Comprehensive Analysis In a study published in JAMA, Dr. Kurian, Scarlett Gomez, PhD, and colleagues compared the use of bilateral mastectomy, breast-conserving therapy (lumpectomy) with radiation, and unilateral mastectomy and the mortality associated with these procedures. The goals were to determine if there were particular types of patients who were likely to receive a bilateral mastectomy and find out if there were relative differences in mortality among the three procedures. “We could address these questions because we used data from the California Cancer Registry, which covers almost all women diagnosed with breast...
A Conservative Approach to Lymph Node Removal

A Conservative Approach to Lymph Node Removal

Until recently, guidelines recommended complete axillary node dissection in women with breast cancer for whom their sentinel node biopsy was positive. However, patients who undergo this procedure routinely experience complications. The introduction of sentinel lymph node biopsy in the 1990s included the benefit of avoiding complete axillary node dissection if two or three sentinel nodes tested negative for cancer, thus reducing morbidity. However, complete axillary node dissection was still used in patients with positive sentinel nodes. The recently completed American College of Surgeons Oncology Group Z0011 (Z-11) trial indicated that women with positive sentinel nodes scheduled for lumpectomy and whole-breast radiation could safely avoid complete axillary lymph node dissection. A Need for Clarity Few studies have compared the risks and benefits of the various axillary interventions for patients with breast cancer. To address this research gap, Roshni Rao, MD, and colleagues performed a systematic review of 17 studies. The analysis, published in JAMA, reviewed studies of women with breast cancer who mostly had benign axilla and received surgical treatment that ranged from removal of one lymph node to removal of all axillary lymph nodes. Outcomes of these procedures were compared with each other as well as with nonsurgical interventions, such as radiation. Women with no suspicious, palpable axillary nodes who underwent breast-conserving therapy did not experience a benefit with complete axillary node dissection when compared with sentinel node biopsy alone. Complete axillary node dissection was associated with a 1% to 3% reduction in axillary lymph node metastases recurrence but was also associated with a 14% risk of lymphedema. Complete axillary lymph node dissection was well suited for patients with...
Guiding Follow-Up Care in Breast Cancer

Guiding Follow-Up Care in Breast Cancer

In 2006, the American Society of Clinical Oncology (ASCO) issued practice guidelines on the follow-up and management of patients with breast cancer who have completed primary therapy with curative intent. Since that time, ASCO completed a 6-year, systematic review and analysis of 14 publications in an effort to update these guidelines. ASCO reissued the recommendations from 2006 in the Journal of Clinical Oncology and came to the conclusion that no revisions to the existing recommendation were warranted. “An important reason behind re-issuing the guidelines is that physicians and patients aren’t always following the recommendations,” explains Thomas J. Smith, MD, a member of the ASCO writing committee for the guidelines. “It has been estimated that more than $1 billion is spent each year on unnecessary breast cancer follow-up care. By re-issuing the guidelines, it’s hoped that clinicians will make greater efforts to adhere to these recommendations.” Assessing Surveillance Research indicates that routine surveillance with PET, CAT, and bone scans—in addition to routine blood tests—is unwarranted in asymptomatic patients with breast cancer. “Physicians tend to deny that they’re ordering these tests, but studies suggest that, in actuality, many clinicians are ordering these diagnostics,” says Dr. Smith. “However, there are no data to date that suggest these tests are beneficial in the management of asymptomatic patients.” Meanwhile, Dr. Smith says other data suggest that patients and physicians do not always obtain tests that are recommended in the guidelines. “Research clearly indicates that patients should undergo a mammogram on the opposite side after definitive surgery for one breast cancer,” he says. “However, study after study has shown that many patients don’t have a...
Breast-Conserving Surgery for Invasive Breast Cancer

Breast-Conserving Surgery for Invasive Breast Cancer

Despite recent improvements in imaging technology, pathology assessments, and the use of systemic therapy, there is still controversy regarding the optimal margin width in breast-conserving surgery. About 25% of patients with invasive breast cancer return to the operating room after undergoing lumpectomy to obtain more widely clear margins. In about half of these cases, the margin is free of cancer cells, defined as no ink on tumor. However, it has long been believed that a larger amount of normal breast tissue might reduce the risk of local recurrence. Recommendations for Breast-Conserving Surgery In 2014, the Society of Surgical Oncology (SSO) and the American Society of Radiation Oncology (ASTRO) released recommendations for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer. “A definitive guideline can help minimize the use of unnecessary surgery while maintaining the excellent outcomes that have been achieved with lumpectomy and radiation therapy,” explains Monica M. Morrow, MD, FACS, who co-chaired the consensus panel that developed the recommendations. To develop the SSO-ASTRO guidelines, leaders in surgical, radiation, and medical oncology as well as pathology and patient advocacy considered a meta-analysis of margin width and ipsilateral breast tumor recurrence (IBTR). The panel conducted a systematic review of 33 studies that included 28,162 patients as the primary evidence base. The panel recommended against the routine removal of larger amounts of healthy breast tissue beyond having no cancerous cells touching the edge of lumpectomy specimens. This recommendation was made regardless of patient age as well as for women with the more aggressive, triple-negative cancer types. “The standard definition of negative margins should be having no ink...

Media Flub: Squeezing Breasts Prevents Cancer?

The media often takes a research study’s findings completely out of context and confuses the public. Researchers from the University of California at Berkeley found that compression of breast cancer cells grown in a laboratory made them assume a normal growth pattern. Reports on this study may have been derailed by the university’s own press release which was entitled “To revert breast cancer cells, give them the squeeze.” The study was presented at a meeting and has not been published. If you read the press release, it is very clear that the research involved only cells. The authors played down any practical use of the information, saying that even a compression bra would probably not be any value. Specifically, they said “Compression, in and of itself, is not likely to be a therapy.” If you google “Squeezing breasts prevents cancer,” you will find over 50 hits. Most of them prominently feature photos of women in various stages of undress and articles with sophomoronic (A word I just made up–a combination of sophomoric + moronic) commentary. Fox News went with “Giving breasts a squeeze could hinder cancer growth.” [Somewhat NSFW photo] The article essentially replicated the Cal Berkeley press release. Here’s one take on the subject from the Daily Beast headlined “He-He Squeezing Breasts Can Prevent Cancer” with the lede “Now this is what you call a titillating breakthrough.” The brief story ended with “Even though the study was a success, the authors caution that it probably won’t lead to a specific cancer therapy. But was it fun?” Cosmopolitan magazine’s headline is “Can Squeezing Your Boobs Prevent Breast Cancer?” The...
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