Guidelines Linked to Reduced Surgery After Lumpectomy for Breast Cancer

MedicalResearch.com Interview with:

Monica Morrow, MD, FACS Chief, Breast Service Department of Surgery Anne Burnett Windfohr Chair of Clinical Oncology Memorial Sloan Kettering

Dr. Morrow

Monica Morrow, MD, FACS
Chief, Breast Service
Department of Surgery
Anne Burnett Windfohr Chair of Clinical Oncology
Memorial Sloan Kettering

MedicalResearch.com: What is the background for this study?

Response: Although we know that bigger surgery does not result in better patient outcomes in breast cancer, since 2005 rates of lumpectomy have been decreasing accompanied by an increase in bilateral mastectomy for unilateral cancer.

High rates of second surgery after initial lumpectomy are one deterrent for patients. In 2013 the SSO and ASTRO developed an evidence based consensus guideline endorsing no ink on tumor as the standard negative margin width for women with stage 1 and 2 cancer having breast conserving surgery with whole breast irradiation. The purpose of our study was to examine time trends in the use of additional surgery after lumpectomy before and after guideline dissemination and to determine the impact of these trends on final rates of breast conservation.

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Rate of Contralateral Prophylactic Mastectomy Varies Among States

MedicalResearch.com Interview with:
Ahmedin Jemal, DVM, PHD

Vice President, Surveillance and Health Services Research
American Cancer Society, Inc.
Atlanta, GA 30303

MedicalResearch.com: What is the background for this study?

Response: Previous studies reported that Contralateral Prophylactic Mastectomy (CPM) increased in the United States among women diagnosed with unilateral early-stage breast cancer with surgery without evidence for survival benefit. Previous studies also reported that receipt of this procedure is more common in younger than older patients, in white than in black patients, and in privately insured than uninsured patients. However, the extent of variation in receipt of CPM by state of residence was unknown.

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Why Are More Breast Cancer Patients Choosing Contralateral Prophylactic Mastectomy?

Dr. Sarah Hawley PhD MPH Associate Professor in the Division of General Medicine University of Michigan Research Investigator, Ann Arbor VA Center of Excellence in Health Services Research & DevelopmentMedicalResearch.com Interview with:
Dr. Sarah Hawley PhD MPH
Associate Professor in the Division of General Medicine
University of Michigan
Research Investigator, Ann Arbor VA Center of Excellence in Health Services Research & Development

 

MedicalResearch: What are the main findings of the study?

Dr. Hawley: There are a couple of main findings.

  • First, we found that nearly 20% of women in our population based sample of breast cancer patients reported strongly considering having contralateral prophylactic mastectomy (CPM, which means they had their unaffected breast removed at the same time as the breast with cancer), and about 8% received it. Of those who did receive contralateral prophylactic mastectomy, most (about 70%) did not have a clinical indication for it, which included a positive genetic mutation of BRCA1 or BRCA2 or a strong family history of breast or ovarian cancer.
  • However, most women (90%) who received it reported having a strong amount of worry about the cancer coming back (also called worry about recurrence).
  • We also found that when women had an MRI as part of their diagnostic work-up for breast cancer, they more often received contralateral prophylactic mastectomy than when they did not have an MRI.

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Bilateral Mastectomy Rates Higher In Hospitals Where Immediate Reconstruction Available

Judy C. Boughey, MD Chair, Division of Surgery Research Mayo Clinic, Rochester, Minn.MedicalResearch.com Interview with:
Judy C. Boughey, MD
Chair, Division of Surgery Research
Mayo Clinic, Rochester, Minn.

MedicalResearch.com: What are the main findings of the study?

Dr. Boughey: Rates of bilateral mastectomy are higher in hospitals with immediate breast reconstruction available. Bilateral mastectomy rates were highest in hospitals with high volumes of immediate breast reconstruction. Large, teaching, urban, and Northeastern hospitals were more likely to have higher immediate breast reconstruction volumes.
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Mastectomy: Use of Paravertebral Block for Pain Control

Judy C. Boughey, MD Chair, Division of Surgery Research Mayo Clinic, Rochester, Minn.MedicalResearch.com Interview with:
Judy C. Boughey, MD
Chair, Division of Surgery Research
Mayo Clinic, Rochester, Minn.

MedicalResearch.com: What are the main findings of the study?

Dr. Boughey: Use of paravertebral block (a form of regional anesthesia) in women undergoing mastectomy results in less need for opioid medications and less frequent use of anti-nausea medication after surgery.

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Breast Cancer in Young Women: Decisions that Affect Contralateral Prophylactic Mastectomy

Shoshana M. Rosenberg, ScD, MPH Researcher, Susan F. Smith Center for Women's Cancers Dana-Farber Cancer InstituteMedicalResearch.com Interview with:
Shoshana M. Rosenberg, ScD, MPH
Researcher, Susan F. Smith Center for Women’s Cancers
Dana-Farber Cancer Institute

 

MedicalResearch.com: What are the main findings of the study?

Answer: Rates of contralateral prophylactic mastectomy (CPM) have been increasing among all breast cancer patients, however this trend has been most pronounced among the youngest women with breast cancer. Because of this trend, we sought to better understand why the youngest women – those diagnosed at age 40 or younger – were deciding to have this surgery.

Many women not considered “high-risk”, e.g., those without a cancer pre-disposing mutation, cited a desire to prevent the breast cancer from spreading as well as a desire to improve survival as reasons for undergoing the procedure, indicating they overestimate the benefit of having this surgery, as CPM does not affect these outcomes. While CPM does reduce the risk of developing breast cancer in the unaffected breast, in women who are not considered “high-risk”, this risk is relatively low, however many women overestimated this risk as well. Continue reading

Study: Chemotherapy is as effective before breast cancer surgery as after

Approach may help some women avoid mastectomy

San Francisco, CA – Whether chemotherapy is given before or after breast-conserving therapy (BCT) does not have an impact on long-term local-regional outcomes, suggesting treatment success is due more to biologic factors than chemotherapy timing, according to a study by researchers at The University of Texas MD Anderson Cancer Center.

Presented today at the 2011 Breast Cancer Symposium, the study also found that neoadjuvant chemotherapy (given before surgery), often shrinks breast cancer tumors, making them more likely to be treatable with BCT, or a lumpectomy to remove a portion of the breast followed by radiation.

“Even women who present with clinical Stage 2 or 3 breast cancer may have good results with BCT after chemotherapy and not need a mastectomy,” said Elizabeth Ann Mittendorf, M.D., assistant professor in the Department of Surgical Oncology and lead author of the study. “The molecular characteristics of the tumor and other factors have an impact on treatment success, but not the order in which chemotherapy and surgery are given.”

The retrospective study of almost 3,000 women treated for breast cancer at MD Anderson from 1987 to 2005 also confirmed several prior studies showing BCT offers high rates of cancer control for certain patients.

Approaches have similar outcomes

Of the patients surveyed, 78 percent had surgery before chemotherapy and 22 percent received chemotherapy first. Overall, women with more cancers that had more adverse prognostic factors tended to be treated with chemotherapy first.

Five and 10-year local-regional recurrence-free survival rates were excellent for both groups: 97 percent and 94 percent respectively for those who had surgery before chemotherapy, 93 percent and 90 percent for patients who received chemotherapy first.

Mittendorf said that if adverse features, such as stage and grade of the cancer, age of the patient and tumor hormone expression, were factored in, survival rates were essentially the same for both groups of women.

Neoadjuvant chemotherapy resulted in complete pathologic response in 20 percent of patients and lowered cancer stage in almost half of patients who had Stage 2 or 3 cancer before chemotherapy, increasing the likelihood that BCT may be effective for many women after chemotherapy.

Carrying results forward

“This study shows that women appropriately selected for BCT, even some women with Stage 3 breast cancer, can have excellent rates of local-regional control,” Mittendorf said. “The most important thing is putting all the factors together to determine who can most benefit from this approach.”

The group plans to extend the study into MD Anderson patients treated after 2005.

“Since 2005, treatment techniques have improved, including the ability to add targeted therapies to chemotherapy,” she said. “In the future we will look at the effects of newer agents, and we anticipate the results will be even more favorable for women who received these treatments before surgery.”

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Other MD Anderson team members included Thomas Buchholz, M.D., Department of Radiation Oncology; Susan Tucker, Ph.D., Department of Bioinformatics and Computational Biology; Funda Meric-Bernstam, M.D., Henry Kuerer, M.D., Ph.D., Isabelle Bedrosian, M.D., Gildy Babiera M.D., Merrick Ross, M.D. and Kelly Hunt, M.D., Min Yi, M.D., Ph.D., Department of Surgical Oncology; Ana Gonzalez-Angulo, M.D. and Gabriel Hortobagyi M.D., Department of Breast Medical Oncology.