Major Advances In Breast Cancer 2014
As 2014 came to an end, just like the years “Top Plays” seen on ESPN, there have been major advances in the care of breast cancer patients. So, here is a list of our “Top Plays”:
- MARGINS – “no ink on tumor” has become the standard for clear margins for invasive breast cancer. What that means is, that as long as the pathologist, does not see tumor cells to the edge of a lumpectomy specimen, the margins are deemed ‘clear’. This is in sharpe contrast to what constituted a clear margin in the past: 1mm? 3 mm? 5 mm? There was no consensus. Now the Society of Surgical Oncology and the American Society for Radiation Oncology issues the “no ink on tumor” consensus statement. Despite the consensus, it must be kept in mind, that to officially ‘clear’ margins, is a multidisciplinary decision, taking into account radiographic findings, the opinion of the surgeon and the radiation oncologist.
- RADIATION OR AXILLARY SURGERY – with microscopic disease in the lymph nodes, the standard treatment was an axillary lymph node dissection (where 10-20 lymph nodes were removed) along with radiation. The treatment had an excellent cure rate, but, carried with it, a high rate of long term complications, such as lymphedema. With the publication of the AMAROS Trial, it was shown that in clinically node negative patients (those without palpable lymph nodes), even if microscopic disease was found in a lymph node, the rate of local recurrence (disease returning in the breast or lymph nodes) was the same, with axillary node dissection (0.43%) vs. axillary radiotherapy (1.19%). So, in keeping with the trends seen the past decade, less surgery is not inferior to more surgery.
- CONTRALATERAL PROPHYLAXIS – women in the United States are undergoing contralateral prophylactic mastectomy (CPM – removal of a normal breast, at the same time a mastectomy is performed on the diseased breast) in ever-increasing numbers. The rate of bilateral mastectomies rose from 2.0% in 1998 to 12.3% in 2011; in women < 40 years of age, the rate was 3.6% in 1998, and was 33% in 2011. However, there is little scientific justification. In the years preceding, the survival from breast cancer improved, while the rates of CPM decreased. It was only recently that the rate of CPM began to rise. There has been data to the contrary, suggesting that CPM, in certain subsets of breast cancer, may increase the breast cancer specific survival by as much as 4.8%. Further complicating the issue, is the 1.5 times complication rates in women undergoing CPM. So, frank discussions with patients is paramount to making informed decisions regarding surgical management.
- GENETIC TESTING – it is becoming increasingly complicated to select the appropriate genetic tests for breast cancer patients. There are many more companies that offer testing. Trained genetic counselor, or, breast oncologists (surgical or medical) should counsel patients as to their risks, and, appropriate testing.