Evaluation, Treatment and Post-Treatment Surveillance of Early Stage Breast Cancer
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Transcript of Evaluation, Treatment and Post-Treatment Surveillance of Early Stage Breast Cancer
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Evaluation, Surgical Treatment, and Post-Treatment Surveillance of
Early Stage Breast Cancer: National Guidelines
Deanna J. Attai, MD, FACSAssistant Clinical Professor of Surgery
David Geffen School of Medicine at UCLA
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No Financial Disclosures
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Breast Cancer Statistics
•Most common type of cancer among women (excluding skin cancer)
•Second most common cause of cancer deaths among women
•1 in 8 women, 1 in 1000 men •Women: 200,000 new cases, 40,000 deaths/year•Men: 2360 new cases, 450 deaths/year
• Incidence and survival vary depending on race, ethnicity, socio-economic status
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Breast Cancer Staging
•Stage 0 – Ductal carcinoma in-situ / DCIS
•Stage I – Tumor <2cm, negative lymph nodes•Stage II – Tumor 2-5cm OR spread to lymph nodes
•Stage III – Tumor >5cm, OR fixed to skin / muscle, OR matted nodes, OR internal mammary nodes
•Stage IV – Metastatic disease (liver, lung, bone, brain most common)
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Preoperative Workup
• History and physical exam• CBC, platelets, LFT, AlkPhos• Diagnostic bilateral mammogram, consider ultrasound• MRI optional• Pathology review, ER/PR and Her2/neu status• Genetic counseling if at risk for hereditary cancer• Fertility counseling if premenopausal• Assess for psychological distress
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Preoperative Workup
•For clinical stage I-IIB additional studies ONLY if directed by signs/symptoms:
•Bone scan localized bone pain or AlkPhos•Abdomen/pelvis CT, MRI, PET/CT elevated LFT, abdominal symptoms, abnormal PE
•Chest CT pulmonary symptoms
•Tumor markers NOT recommended
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Team Approach
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Breast Cancer Surgery
• First described 1500s• General Anesthesia 1840s• Halsted Radical Mastectomy:
1894-1960-70’s
• Halsted died in 1922
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CANCER
LYMPH NODE
FISHER THEORY
LUNGS
LIVER
BONE
BLOOD STREAM
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Dr. Bernard FisherNSABP B04 Enrollment 1971-1974
www.NSABP.edu
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Fisher B et al. N Engl J Med 2002;347:567-575.
NSABP B04 Results
• Preservation of the pectoral muscle new standard of care• 2 step procedure should be performed
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NSABP B06 Enrollment 1976-1984
www.NSABP.edu
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NSABP B06 Results
Fisher, et al N Engl J Med,Vol. 347, No. 16 · October 17, 2002
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NSABP B06 Results
• No difference in survival at 20 years
• Lumpectomy without postoperative irradiation higher local recurrence 39.2% vs. 14.3%
• BCS New standard of care for Stage I/II
Fisher, et al N Engl J MedVol. 347, No. 16 · October 17, 2002
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Breast Surgery
• May need re-evaluation due to national increase in mastectomy rates for early stage breast cancer
• NCCN does not indicate preference for surgery
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Surgical Technique
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“The NCCN panel accepts ‘no ink on tumor’ from the 2014 SSO-ASTRO Consensus Guideline on Margins”
Surgical Margins
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Surgical Margins
“The ASCO review panel endorses the SSO/ASTRO recommendations with qualifications… reinforces and amplifies the guideline authors’ call for the monitoring of outcomes at the institutional level”
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Importance of Axillary Lymph Node Status
• Node status determines stage, predicts outcome• Node status influences adjuvant therapy decisions:
- Chemotherapy, anti-estrogen therapy- Drug choice, dose, combination- Radiation therapy
• Positive nodes in ~ 5-30% clinical stage I & II patients• High rate of lymphedema, paresthesias, shoulder
dysfunction. No benefit in node-negative patients
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History of Axillary Lymphadenectomy
• Petit 1774 • Pancoast 1884 • Halsted 1895 • Patey 1948 • Krag, Morton, Giuliano, Tafra, Ross, Reintgen, 1990s
- Sentinel Node
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Development and Validation of Sentinel Node Biopsy Technique• Morton, D, et al. Technical Details of Intraoperative Lymphatic Mapping for Early Stage Melanoma Arch Surg. 1992;127(4):392-399
• Krag DN, et al. Surgical resection and radiolocalization of the sentinel lymph
node in breast cancer using a gamma probe. Surg Oncol 1993;2:335-339
• Giuliano AE, et al.Lymphatic mapping and sentinel lymphadenectomy for breast
cancer. Ann Surg 1994;220:391
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Sentinel Lymph Node Dissection
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Sentinel Node BiopsyNSABP B32; Enrollment 1999-2004
Mamounas, EP Clin Med Resv.1(4); 2003 Oct
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NSABP B32 Results• 5,611 patients, 80 sites, 232 surgeons• SN Identification rate 97%• 26% had positive node• 9.7% false negative rate; less common with >1SN, more
common if excisional biopsy performed first• OS, DFS, Regional Control statistically equivalent
• SNB alone is safe, appropriate, and effective in patients with clinically negative nodes
• Lumpectomy AND mastectomy patients
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Positive Sentinel Node (891 patients)Axillary
Dissection (445)
No axillary
Dissection (446)
Positive Sentinel NodeACOSOG Z0011 Trial
• No difference in OS or DFS• 70% vs. 25% wound infections, axillary seromas, paresthesias• Lymphedema 13% vs. 2%; longer term after SNB 5-8%
Giuliano AE, et alJAMA 2011;305:569-75
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ACOSOG Z0011 Change in Practice
Breast Conservation Patients•No intraoperative frozen section•No ALND if 1-2 positive nodes
Other Patient Populations?•Mastectomy, APBI, Neoadjuvant Therapy•AMAROS Trial - Radiation shown to be as effective as AXND, lower morbidity
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Surgical Axillary Staging
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Surgical Axillary Staging
• Women without SLN metastasis should not receive ALND• Women with 1-2 metastatic SLNs planning to undergo breast
conserving surgery with WBR should not undergo ALND
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Surgical Axillary Staging
• Sentinel node biopsy for Stage I-II patients• NCCN includes Stage IIIA• Lumpectomy and mastectomy
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Immediate Reconstruction•Most patients are a candidate unless locally advanced or inflammatory cancer
• Implant or free flap (fat and skin); less commonly muscle flap used
•Skin-sparing / NAC-sparing mastectomy with reconstruction can result in minimal scarring
•Collaboration with breast surgeon, plastic surgeon, medical oncologist, and radiation oncologist is crucial for optimal results
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Federal Legislation
•Women’s Health and Cancer Rights Act of 1998
• Insurers who cover medical / surgical treatment for breast cancer must cover:
• Ipsilateral mastectomy reconstruction•Surgery / reconstruction of other breast for symmetry•Prostheses and lymphedema management
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Reconstructive Surgery
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Reconstructive Surgery
• All women should be educated about reconstructive options • Oncoplastic techniques can increase breast conservation• NAC-sparing may be an option in patients who are carefully
selected by experienced multidisciplinary teams
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Reconstructive Surgery Options
• Tissue expander -> Implant• Direct to implant• Latissimus flap• Free flap (DIEP and others)• Oncoplastic reconstruction • Fat grafting after lumpectomy or mastectomy
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Nipple Sparing Mastectomy
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Target enrollment: 2000 cases
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NSM / Implant
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NSM / DIEP
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Lumpectomy / Oncoplastic Reduction
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Post-treatment Surveillance
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Post-treatment Surveillance
• Regular history, PE and mammography recommended• Physical exam
• q 3-6 months x 3 years• q 6-12 months years 4-5• Annual after year 5
• Breast conserving surgery• Post-treatment mammogram no earlier than 6 months after radiation, or at 1 year after initial study
• Resume annual imaging unless otherwise indicated
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Post-Treatment Surveillance
•NOT RECOMMENDED for asymptomatic patients:•CBC, chemistry panels, LFTs•Tumor markers CEA, CA 15.3, CA 27.29•Breast MRI•Chest x-ray•Liver ultrasound•Pelvic ultrasound•Chest / Abdomen / Pelvis CT, MRI, PET/CT
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References
•National Comprehensive Cancer Network• www.NCCN.org
•National Accreditation Program for Breast Centers• https://www.facs.org/quality%20programs/napbc/standards
•American Society of Clinical Oncology• http://www.instituteforquality.org/practice-guidelines
•The American Society of Breast Surgeons• https://www.breastsurgeons.org/new_layout/about/statements/index.php