BREAST CANCER TODAY
| EVALUATION OF BREAST CANCER PATIENTS —Anna Marie Wallace, MD, Assistant Professor of Surgery,
Associate Director of Breast Multidisciplinary Program, University of New Mexico Health Sciences Center, Albuquerque
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 | Core needle biopsy: considered standard of care by American Society of Breast Surgeons (possible legal implications
if not offered); provides histologic profile (eg, invasive vs in situ disease), estrogen receptor /progesterone
receptor (ER/PR) status, and HER2-neu status
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| Fine needle aspiration (FNA): used in some cases; need pathologist trained in cytopathology with adequate case
volume in FNA analysis of breast cancer
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| Incisional biopsy: rarely used; consider in patient with osteogenic component
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| Excisional biopsy: no longer standard of care; disadvantages—many lesions in upper outer quadrant; excisional
biopsy can transect lymphatics in upper outer quadrant (where many breast cancers arise) and compromise accuracy
of sentinel lymph node biopsy (SLNB); associated with higher rate of reexcision due to close or transected
margins; cannot perform axillary staging during excisional biopsy; can result in large scar and large volume decrease
in breast, despite diagnosis of benign disease; can miss opportunity for diagnosis of metastatic disease
(axillary staging procedure not done at same time; avoid operating on patients with metastatic disease); good
margins difficult to get in patient with locally advanced disease; can negate opportunity for patient with locally
advanced disease to undergo neoadjuvant therapy or to find out which chemotherapy most effective for her tumor;
studies show 40% to 60% of patients require reexcision because of close or transected margins after excisional
biopsy (compared to 20%-30% for lumpectomy); when to consider—if core needle biopsy technically
difficult (too close to skin or chest wall or in some cases where implant present); if imaging studies show benign
lesion in low-risk patient; if patient refuses core needle biopsy
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| Treatment approach: genetic testing and counseling—consider if patient <40 yr of age at diagnosis with lack of
family history, or in patient with first-degree relative(s) with breast or ovarian cancer (indicates BRCA mutation;
changes recurrence rate and risk for contralateral disease); magnetic resonance imaging (MRI)—consider for diagnosis
and screening; can determine whether breast conservation possible, whether chest wall involved, whether
extralymphadenopathy present, and to define extent of cancer in patient with dense breast tissue; consultations
and referrals—consider sending patient to see radiation oncologist and/or plastic surgeon before breast conservation
or mastectomy surgery (helps reduce patient anxiety and aids in treatment decision-making); consider referral
to medical oncologist to discuss neoadjuvant chemotherapy if tumor approaching 3 cm in size
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| Staging issues: standards of care well delineated by National Comprehensive Cancer Network (NCCN) guidelines;
history and physical examination—assess for chest pain, shortness of breath (determine cardiac status for anesthesia
and presence of pleural effusion), and bone pain; evaluate patient for nipple discharge, skin changes, chest wall
involvement, lymphadenopathy, and family history of breast or ovarian cancer; imaging studies—obtain mammography,
ultrasonography (US), and MRI when appropriate; need radiologic study (at least US) before going to operating
room (OR); biopsy—core needle biopsy required; stage 1—tumor <2 cm; no palpable lymph nodes; obtain
chest x-ray, liver function tests (LFTs), and complete blood cell count (CBC) with platelet count; stage 2a and 2b—
mass approaching 3 cm in size; palpable lymph nodes; get computed tomography (CT) of abdomen and bone scan;
stage 3a and above—do formal staging even in patients without symptoms or with normal LFTs or chest x-ray; order
studies in patient with symptoms or test abnormalities (regardless of patient’s apparent stage during initial evaluation)
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| Handling surgical specimen: specimen radiography—use during wire localization; document removal of wire,
tip, and clip; 1-cm margin around mass desirable; remove skin overlying tumor if tumor close to skin; remove fascia
if tumor close to chest wall; orient specimen using preferred technique; frozen sections—on sentinel lympth node
(SLN) to provide intraoperative answer; if positive, do completion axillary dissection while patient still in OR; rarely
indicated for breast parenchyma; use permanent processing on breast parenchyma; send axillary dissection specimens
for permanent processing; get ER/PR and HER2-neu status on invasive cancer; get ER/PR on in situ components
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| Ductal carcinoma in situ (DCIS): pectoralis fascia good barrier; fascia anatomic border for breast tissue; NCCN
guidelines for DCIS—1 mm inadequate margin; 2 mm smallest margin acceptable
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| Invasive breast cancer: pectoralis fascia not adequate barrier; remove muscle directly underlying area of tumor if
margin close to chest wall (can go down to level of intercostal muscles and radiate chest wall afterward); infiltrating
status 2 mm
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| Axillary dissection: either perform SLN dissection or level 1 and 2 axillary dissection (no literature to support anything
in-between); SLNB—requires experienced team and patient with no previous hormonal therapy or chemotherapy;
possibly less accurate in patient with multicentric disease; avoid in tumors >5 cm; avoid in patient with palpable
lymph nodes, large upper outer quadrant excisions, and previous axillary infections; make sure SLN stained blue, has
blue-stained lymphatic leading to it, and/or takes up radioactive tracer; remove palpable nodes; do formal level 1 and
2 dissection if SLN not found (avoid “berry picking”); internal mammary nodes optional (use standard processing)
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| Adjuvant therapy: with multidisciplinary approach, 33% difference in mortality rates; indications for
chemotherapy—patient with 1-cm invasive disease; patient with <1-cm disease, but unfavorable histology (especially
if hormone-receptor negative); consider in young patient, even if tumor not exactly at cutoff size; consider chemotherapy
if lymph nodes involved; neoadjuvant chemotherapy—consider if tumor approaches 3 cm; consider in
patient with skin or chest wall involvement; always indicated in patient with inflammatory breast cancer;
radiotherapy—always indicated after lumpectomy; requires time commitment; irradiation of lymph node basin required
if 4 positive lymph nodes in axilla, if lymph node mass very large, or if extranodal extension present; chest
wall irradiation necessary if tumor 5 cm and/or if chest wall involved; radiation usually done after surgery and chemotherapy;
trials looking at partial breast irradiation (done immediately after surgery)
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| BREAST IMAGING AND BENIGN DISEASE —Rosemary Leeming, MD, Assistant Professor of Surgery, and
Medical Director of University Hospitals Health System, Chagrin Highlands Breast Center, Orange Village, OH
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| Mammographic screening: guidelines—annual screening beginning at 40 yr of age; if patient has family history
of breast cancer, start screening 10 yr before age of diagnosis of relative; Digital Mammographic Imaging Screening
Trial (DMIST)—50 000 women enrolled in trial; women who benefited most from digital mammography included
women <50 yr of age, women with dense breasts, and pre- or perimenopausal women; digital
mammography associated with same disadvantages as film mammography; US—considered adjunct to mammography
or physical examination; efficacy operator-dependent; significant false-negative and false-positive rates; useful
in evaluating mammographic findings and evaluating vague palpable areas of breast tissue; MRI—tissue
density not factor; high sensitivity for invasive cancer; probably not as sensitive for DCIS; high false-positive rate,
so do not biopsy based on MRI alone; expensive; takes 1 hr to complete; indications include high-risk screening
(eg, genetic predisposition or known BRCA mutation) and in pretreatment and posttreatment evaluation with neoadjuvant
therapy; useful in women with denser breast tissue (to look for multicentric disease), and for breast implant
evaluation
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| Pathophysiology of benign breast disease: hormonal factors—estrogen responsible for duct elongation;
progesterone develops lobules and alveoli; prolactin involved in milk production; these hormones all involved in
disease processes; fibrocystic changes extremely common; classification and risk—benign breast disease classified
as nonproliferative, proliferative, and proliferative with atypia; long-term study found two-thirds of patients biopsied
had nonproliferative lesions with relative risk of 1.27; family history increased relative risk to 1.62; 30% of
patients had proliferative lesions without atypia with slightly higher relative risk (1.88; family history less significant
than histology); small percentage of patients had proliferative lesions with atypia; associated with higher risk
(relative risk 4.24; family history least impact); risk includes both breasts; association of risk and age—women
<45 yr of age with atypia have nearly twice the risk of those diagnosed after 55 yr of age; increased risk persisted
over time
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| Clinical features and management
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| Breast pain: cyclic pain related to menstrual cycle common condition; treat with nonsteroidal anti-inflammatory
drugs (NSAIDs), diet changes, and fatty acid supplementation (eg, vitamin E, evening primrose oil); reassure patient
not breast cancer; studies suggest tamoxifen or danazol useful in severe breast pain; localized noncyclic
pain (not related to menstrual cycle) may indicate fluid-filled cyst or cyst rupture; consider patient mistaking
chest wall pain for breast pain; consider arthritic conditions of chest wall, herpes zoster, and fibromyalgia; consider
cardiac or gallbladder symptoms in patient with left-sided breast pain
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| Nipple discharge: determine whether discharge spontaneous or elicited; spontaneous discharge indication of pathology;
ask patient about timing, frequency, and character of discharge (eg, milky, bloody, clear,); ask about
medication use (eg, antidepressants); determine if discharge coming from single or multiple ducts; galactorrhea
or milky discharge typically bilateral; check prolactin and thyrotropin levels; ask about medication use; if discharge
not milky, determine whether discharge coming from solitary duct or multiple ducts; obtain cytologic
evaluation (however, negative cytology does not preclude further evaluation); consider ductography or ductoscopy
if discharge appears to stem from solitary duct (negative ductography or ductoscopy should not preclude
surgical evaluation); surgical considerations—evaluation indicated in cases of solitary duct discharge, abnormal
cytologic findings (including blood), or positive imaging studies; surgical treatment involves duct excision; consider
ductoscopy; review potential risks with patient, eg, decreased sensitivity or flattening of nipple and inability
to breast-feed
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| Breast masses: etiology—age-dependent; in women <30 yr of age, fibroadenoma most common; in women 30 to 50
yr of age, cysts, fibrocystic changes, and hyperplasia most common; in women >50 yr of age, cysts or cancer most
common; cyst classification—US classification includes simple cysts, complex cysts, or solid masses; evaluate
any breast mass not deemed simple cyst; if triple test (ie, palpation, imaging, and cytology or core biopsy) results
concordant in indicating simple cyst, accuracy 99%; proceed with evaluation if results of triple test discordant;
cyst evaluation and follow-up—simple cysts do not require aspiration; recurrent or bloody cysts require cytologic
evaluation and possibly biopsy; complex cysts require follow-up or aspiration and biopsy; solid breast masses—
always require evaluation with cytology or biopsy; excision not always necessary, but definite diagnosis necessary;
patient requires follow-up even if core biopsy shows fibroadenoma; excision not necessary for biopsy-
proven benign lumps, unless lesion >2 to 3 cm or enlarging
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| Breast biopsy: FNA useful in some cases; recommend core biopsy when mass palpable; incisional biopsy appropriate
in some patients; excisional biopsy less common
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| Breast cancer prevention: determine risk status using Gail or Claus model and BRCA status; educate patient on
options, including observation, chemoprevention, or prophylactic mastectomy; tamoxifen effective at reducing
rates of noninvasive and invasive cancer; raloxifene effective at decreasing rates of invasive breast cancer in postmenopausal
women; consider chemoprevention in women who meet Gail criteria of >1.66%; consider prophylactic
mastectomy in women at high risk (eg, BRCA carrier, patient who had contralateral breast cancer and good prognosis)
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| NATIONAL PROGRAMS IN IMPROVING QUALITY OF BREAST CANCER CARE —Stephen B. Edge, MD,
Professor of Surgery and Oncology, Roswell Park Cancer Institute, University of Buffalo School of Medicine, Buffalo,
NY
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| Provider as factor in treatment outcome: study data—60% of surgeons in Los Angeles treated one breast cancer
case per year; patient treated at hospital that treats <10 cases per year (30% of hospitals) had 1.6 relative risk of
5-yr mortality; treatment at low-volume hospital by low-volume surgeon associated with greater risk for death than
treatment at high-volume hospital by high-volume surgeon; patient treated at low-volume hospital twice as likely
to miss recommended adjuvant therapy; availability and use of coordinated programs to treat cancer may explain
volume-outcome association; recommended that surgeons in low-volume practices have mechanisms in place to
ensure all patients receive appropriate care
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| Improving treatment outcomes: passive use of guidelines and feedback information ineffective; beneficial to
define multidisciplinary teams and pathways for treatment by those teams; quality of care gauged using process-of-
care measures (survival alone not sufficient)
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| Breast cancer treatment measures: 1) recommend breast-conserving surgery followed by radiotherapy in
women <70 yr of age within 1 yr of diagnosis; 2) chemotherapy administered within 120 days of diagnosis in patient
with hormone receptor-negative breast cancer; 3) tamoxifen or third-generation aromatase inhibitors considered
or administered in patients with hormone receptor-positive disease; applied through American College of
Surgeons’ (ACS’) Commission on Cancer (CoC) approvals program (national system for applying treatment measures,
including data collection structure, centralized data storage and analysis, and existing structure for feedback
and reporting to providers); CoC developed Cancer Program Practice Profile Reports (CP3R) program for reporting
quality of care to hospitals for all approved programs; ACS coordinating effort to establish standards and accreditation
of breast centers; objectives include consensus development of standards for breast centers,
strengthening scientific basis for quality of care, establishing survey process, establishing national breast disease
registry, and promoting participation in clinical trials
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Suggested Reading
Christian CK et al: A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a
study of the National Comprehensive Cancer Network. Ann Surg 243:241, 2006; Katz SJ et al: Patterns and correlates
of patient referral to surgeons for treatment of breast cancer. J Clin Oncol 25:271, 2007; Lehman CD et al:
MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med 356:1295,
2007; Shin S et al: Follow-up recommendations for benign breast biopsies. Breast J 12:413, 2006; Smith RA: The
evolving role of MRI in the detection and evaluation of breast cancer. N Engl J Med 356:1362, 2007; Wallace AM
et al: Breast imaging: a surgeon's prospective. Nucl Med Biol 32:781, 2005; Wallace AM et al: Rates of reexcision
for breast cancer after magnetic resonance imaging-guided bracket wire localization. J Am Coll Surg 200:527,
2005.
Educational Objectives
| The goal of this program is to improve the diagnosis and management of breast cancer and other breast-related disease.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Compare the options for biopsy in a patient with breast cancer.
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| 2. Utilize the current recommendations for staging a patient with breast cancer.
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| 3. Describe the options for breast imaging in benign breast disease.
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| 4. Discuss the pathophysiology, clinical features, and management of benign breast diseases.
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| 5. Take advantage of the programs currently available for improving the quality of care in breast cancer patients.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Wallace was recorded September 6-8, 2006, in Albuquerque, NM, at Current Concepts in General Surgery and
Trauma Update, sponsored by the University of New Mexico Health Sciences Center, Department of Surgery and
Office of Continuing Medical Education. Dr. Leeming was recorded November 10-11, 2006, in Cleveland, OH, at the
2nd Annual Surgery Update Course, sponsored by Case Western Reserve University School of Medicine, Department
of Surgery. Dr. Edge was recorded September 16-17, 2006, at General Surgery 2006, in Sacramento, CA, sponsored
by the University of California, Davis, Health System. The Audio-Digest Foundation thanks Drs. Wallace,
Leeming, and Edge and the sponsors for their cooperation in the production of this program.
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