Issues In Breast Care

Educational Objectives

The goal of this program is to improve management of breast health by reviewing current issues in breast cancer screening and breast surgery. After hearing and assimilating this program, the clinician will be better able to:

1.   Describe the benefits and consequences of screening mammography for women of different age groups.

2.   Assess the effects of patient characteristics, such as hormone therapy, family history, and breast density, on breast cancer detection and survival.

3.   Implement measures to reduce the likelihood of false-positive and false–negative results in breast cancer screening.

4.   Explain surgical techniques used in breast reduction.

5.   List complications of surgeries for breast reduction, reconstruction, and augmentation.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee 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 and planning committee reported nothing to disclose.

Acknowledgments

Dr. Kerlikowske was recorded at Controversies in Women’s Health, sponsored by the University of California, San Fran­cisco, School of Medicine, Division of General Internal Medicine, and held December 4 -5, 2008, in San Francisco, CA. Dr. Fletcher was recorded at 27th Annual OB/GYN Update, sponsored by HealthPartners Institute for Medical Education, and held April 2-3, 2009, in Oakdale, MN. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooper­ation in the production of this program.

Current Strategies in the Detection of Breast Cancer

Karla Kerlikowske, MD, Professor of Medicine and Professor of Epidemiology and Biostatistics, University of California, School of Medicine, San Francisco; Director, Women Veteran's Comprehensive Health Center, Vet­erans Affairs Medical Center, San Francisco, CA

Overview of screening mammography: for asymptomatic women; goal to look for suspicious abnormalities; does not diagnose breast cancer (separates women into high- or low-risk groups); 2-view mammography  —  standard of care in United States; craniocaudal and mediolateral oblique; 1-view mammography  —  used in Europe; mediolat­eral view only; goals  —  prevent deaths; improve cosmesis (eg, lumpectomy instead of mastectomy); decrease over­all mortality; provide early detection (not prevention) of breast cancer

Benefits of screening mammography

Women 40-49 yr of age: trial in United Kingdom (2006)  —11-yr follow-up; »16% decrease in breast cancer mortal­ity among screened vs nonscreened women at 10 to 11 yr; Canadian trial (1980s)  —  showed no effect; take-home message  —  modest benefit observable only with long follow-up; number needed to screen (NNS)  —  2500 women 40 to 49 yr of age to avert 1 death (25,000 annual mammograms); most studies done in United Kingdom; US case-control studies (Elmore 2005 and Norman 2007)  —  no difference in mortality; case-control studies usually overestimate benefit

Women ³50 yr of age: 30% reduction in mortality in screened women; benefit seen in ³5 yr; tighter confidence in­tervals; benefit persists over long period; NNS  —270 women every 2 yr for 20 yr to avert 1 death (ie, 2700 mam­mograms)

Women ³70 yr of age: little data available on mortality in randomized controlled trials (RCTs); population-based data  —  better detection in screened group, but no significant difference in mortality

Screening vs treatment effects on mortality: Surveillance, Epidemiology and End Results (SEER) treatment data  —survival rate for localized, regional, and distant disease; 5-yr survival (1983-1990 and after) improved for all (sug­gests treatment decreases mortality); SEER screening data  —  screening increased detection of in situ disease and localized invasive cancer; only modest decrease in regional cancer; no change in distant disease; some cancers may regress or stay dormant; in many cases, unclear whether early cancers would have become regional disease; New England Journal of Medicine (Berry, 2005)  —  modeling study; from 1990 to 2003 in absolute terms, death rate of 33 in 100,000 decreased to 25 in 100,000; likely 4 deaths averted by screening and 4 by treatment; overall mortality  —  for women 50 to 69 yr of age, Swedish trials show decrease; for women in 40s and 70s, no change

Question: How often should women 50 to 69 yr of age undergo mammography? A) every year; B) every 1 to 2 yr; C) every 2 yr; D) every 3 yr

Answer: C) every 2 yr; RCTs comparing annual vs biennial screening  —  no difference in breast cancer mortality; population-based data (Breast Cancer Surveillance Consortium)  —  from United States; looked for increase in late-stage disease with biennial vs annual screening; proportion of advanced-stage disease decreases with age (tu­mors not as aggressive in older women); in women ³50 yr of age, proportion of advanced-stage cancer same with annual and biennial screening ; for younger women (40-49 yr of age), 21% of cancers late-stage disease in annual group vs 28% in biennial; 7% difference may warrant annual screening; Canadian study  —  annual vs biennial screening in women 50 to 69 yr of age; 10-yr survival same

Patient characteristics and breast cancer

Hormone therapy (HT): taking estrogen and progestin for >5 yr increases rate of cancer and advanced disease; explanations  —  estrogen and progestin promote tumor growth, increase breast density, and mask tumors; only »15% of postmenopausal women now using hormone therapy; decreased use associated with lower incidence of breast cancer (particularly estrogen receptor–positive disease [13% per year])

Breast density: reported with some mammograms (eg, fatty, scattered fibroglandular densities, heterogeneously dense, very dense); most women in middle of range; effect of breast density on detection  —  higher density both increases risk for breast cancer and makes it more difficult to detect; unpublished data  —  higher density corre­lates with more advanced disease; consider annual screening, or use of digital mammography

Family history (first-degree relative): no effect on ability to detect cancer; more abnormalities noted and biopsies performed, possibly due to clinician bias; survival study  —  no difference with positive family history; screening  —  not necessary to screen more often

Obesity: increases risk for breast cancer and advanced disease; attributed to extra estrogen in adipose tissue, rather than to difficulties with detection

Potential Consequences of Screening

Overview: 30% to 50% chance that women will have abnormal result after 10 screening examinations at effective fa­cilities; mammography lacks specificity; abnormality leads to additional testing that can cause lasting anxiety for some women

Causes of morbidity: procedures  —  eg, core biopsies (requires large-gauge needle and several punctures); overtreatment  —  screening detects biologically insignificant lesions (do not need treatment); 20% to 25% more treatment in screened vs unscreened population (possibly some unnecessary); pain  —  speaker advises patients to take nonsteroidal anti-inflammatory drug 30 min before mammography; radiation-induced cancer  —  theoretic (ex­trapolated from breast cancer rates in lymphoma patients after radiation therapy to chest); incidence estimated at 1 in 10,000 women screened annually for 10 yr

Age and screening (US data): mammography less specific in younger women; more negative consequences from screening; positive predictive value 2 in women 40 to 49 yr of age; sensitivity and specificity increase with age; 30% chance of  ³1 positive mammogram with annual screening starting at 40 yr of age; 10% chance of 1 biopsy (not cumulative)

Minimizing false positives and negatives: limit hormone use; avoid biopsy by using comparison films; encourage weight loss (increased breast tissue leads to more false positives); refer to high-volume facilities (have better speci­ficity); counsel patients that breast augmentation decreases sensitivity of mammography

Ductal carcinoma in situ (DCIS): premalignant lesion; since 1985, 500% increase in frequency of DCIS detection; now 1 in 1300 screening examinations result in DCIS diagnosis; 20% of all breast cancers; data suggest lesion of low malignant potential (only  15% of lesions progress to invasive cancer in 10 yr); risk for death low (1%-2%) with all treatments (eg, lumpectomy, radiation therapy, tamoxifen); prevalence at autopsy  —  easy to find, suggest­ing that some DCIS lesions stay dormant; breast cancer incidence  —  no decrease associated with detection of DCIS; rate of DCIS doubles between 40 and 70 yr of age, with insignificant effect on mortality; utility of mammog­raphy questionable at >70 yr of age

Cost-effectiveness: compare benefit to harm; women 50 to 69 yr of age  —  most cost-effective; $21,400/yr of life saved; smoking cessation much more effective way to reduce clinical burden of disease and costs

Current recommendations: most organizations recommend screening at ³40 yr of age; in United States, no upper age limit (may change); American College of Physicians  —never recommended mammography for women 40 to 49 yr of age; take-home message  —  mammography not necessarily mandatory for women 40 to 49

Question: sensitivity of digital mammography higher than film mammography for which groups of women? A) pre­menopausal; B) 40 to 49 yr of age; C) with dense breasts; D) all of these

Answer: D) all of these (must fall into all 3 categories [»50% of women 40 to 49 yr of age]); women >65 yr of age with fatty breast tissue  —  film mammography gives better contrast

Question: women at high risk for breast cancer should undergo which screening tests? A) mammography; B) clinical breast examination (CBE); C) ultrasonography; D) mammography and ultrasonography; E) mammography and magnetic resonance imaging (MRI); F) mammography, CBE and MRI

Answer: no correct answer; depends on definition of high risk; mammography and MRI  —  standard of care for carri­ers of breast cancer mutation; MRI twice as sensitive as mammography, but less than half as specific; tests usually alternated every 6 mo for mutation carriers

American Cancer Society recommendations: MRI for high-risk women; high risk  —  lifetime risk 20% to 25% or higher (ie, in sporadic cancer, not mutation carriers [40%-80% risk])); 20% to 25% or higher risk category  —  use Gail model; 5-yr and lifetime risk; unclear how MRI benefits high-risk women compared to mutation carriers; new models for calculating lifetime risk might incorporate breast density

Question: average-risk women should undergo which breast examinations in addition to mammography? A) CBE; B) BSE; C) CBE and BSE; D) none of these

Answer: D) none of these; CBE  —  sensitivity 54%; does not decrease mortality when combined with mammography; increases false positives

Effectiveness of BSE: 3 large RCTs in China, Russia, and United Kingdom  —  BSE vs usual care; after long follow-up, no difference in mortality; speaker does not train residents to teach BSE; potential consequences  —  increase in benign biopsies and physician visits

Speaker’s recommendations: inform women of potential benefits and consequences of screening; in women 50 to 69 yr of age, mammography every 2 yr and consider CBE in women who refuse; in women ³70 yr of age, stop mammography and consider CBE in patients who request it

Breast Reduction and Augmentation

James W. Fletcher, MD, Assistant Professor, Department of Surgery, University of Minnesota Medical School, Minneapolis

Overview: important to understand indications, select patients appropriately, and temper patients’ expectations; pa­tient should research surgeons’ outcomes (look at photographs) and check for board certification in plastic surgery; no state legislature limits scope of practice

Breast Reduction

Patient selection: somatic complaints  —  insurance will reimburse; data show validated spinal posture, scoliosis scores, and pain scales improve dramatically after surgery; problems common among patients with large breasts

Complication rate: similar to that of other operations; smokers  —  wound healing problems common; inform patient; discrepancies  —  size, shape, and symmetry; often predate surgery; changes in nipple-areolar complex  —  most com­monly, patients experience changes in sensation (eg, in larger breasts, increased nipple tenderness postsurgery); loss or gain in sensibility over time; breastfeeding  —  continuity of lactiferous ducts to nipple left intact, but surgery causes scarring of area; some patients report increased difficulty; pigmentary changes  —  more common in women with darker complexions (eg, Fitzpatrick skin types IV and V)

Degree of reduction: Schnur's table  —  based on body mass index (BMI); gives number of grams medically necessary to remove (surgeon must comply to ensure insurance reimbursement); eg, BMI of 30  —  remove »300 g from each breast; discuss degree of reduction with patient

Breast anatomy: connection of lactiferous ducts to nipple left intact in almost all techniques; lymphatics  —  parallel nerve structure; those in fourth interspace and perforator flaps most important; preserving nipple function  —maintain lymphatic supply, lactiferous ducts, and nerve supply in central mound of breast tissue

Techniques: inferior pedicle resection  —  used by »95% of plastic surgeons in United States; extra skin resected, leav­ing open area; tissue underneath resected, and flap of skin (clamshell) near clavicle elevated; central portion of breast skeletonized (nerves and vessels left intact); pull clamshell down and create new brassiere out of remaining skin; also called “inverted T” or anchor-type incision; easy and predictable; can keep central pedicle of tissue alive; short-scar techniques  —  technically more challenging; takes months for breasts to settle; variations on pedicle orientation  — top of breast or bottom; same as inverted T scar

Breast Mastopexy

Overview: purely cosmetic in most cases; techniques similar to reduction; common to have excess skin envelope (eg, after pregnancy or drastic weight loss); indications  —  severe asymmetry in developmental adolescent years; con­genital absence of breast (eg, Poland syndrome); asymmetry in breast reconstruction; insurance reimbursement  —  difficult to obtain; breast cancer reconstruction  —  operations for symmetry mandated by law; speaker’s most com­mon patient type

Complication rates: similar to those for reduction; if purely cosmetic, important to discuss scarring with patient; changes in sensibility and performance of nipple-areolar complex; Regnault classification  —  nipple normally at same axis as inframammary crease; as it descends, greater amount of surgery (and resultant scarring) necessary; scarring  —  depends on degree of breast ptosis and tissue acceptance; periareolar scar most common; with greater resection of skin, scar patterns may resemble “tennis racquet,” “lollipop,” or “anchor”

Mastopexy with augmentation: implant placed beneath gland or muscle; rotation of nipple inferiorly  —  may be cor­rected by restoring breast volume with implant

Breast Augmentation

Implants: silicone recently reapproved by Food and Drug Administration (FDA); FDA-mandated study  —  75,000 women reconstructed with implants postmastectomy; £7 yr of follow-up; silicone and saline implant complica­tions identical in type (eg, rippling, breaking, scarring) and severity; no increase in risk for arthritis or other sys­temic problems relative to women without implants

Positives: low complication rates and high general satisfaction in properly selected patients; long-term monitoring  —can visualize parenchyma using displacement or Eklund mammography; data strongly suggest in­creased breast cancer survivorship at 5 yr in patients with implants (reason unknown)

Negatives: replacement of implants required after »10 yr (inform patient about lifetime commitment to surgery); removing implant may necessitate breast lift and create additional scarring; complications  —  infections; asymme­try; altered nipple sensibility; contracture; scarring; injection techniques (eg, oil and paraffin)  —  associated with long-term complications; implant size  —  linearly related to number of complications

Suggested Reading

Berry DA et al: Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 353:1784, 2005; Cook AJ et al: Decreased accuracy in interpretation of community-based screening mammography for women with multiple clinical risk factors. J Clin Epidemiol Sep 8, 2009 [Epub ahead of print]; Dignam JJ et al: Estimating breast cancer-specific and other-cause mortality in clinical trial and population-based cancer registry cohorts. Cancer 115:5272, 2009; Elmore JG et al: Efficacy of breast cancer screening in the community according to risk level. J Natl Cancer Inst 97: 1035, 2005; Losken A, Hamdi M: Partial breast recon­struction: current perspectives. Plast Reconstr Surg 124:722, 2009; Maxwell GP, Gabriel A: Possible future development of im­plants and breast augmentation. Clin Plast Surg 36:167, 2009; Moss SM et al: Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: a randomised controlled trial. Lancet 368:2053, 2006; Norman SA et al: Protection of mammography screening&