DIFFICULT PROBLEMS IN BREAST CANCER DIAGNOSIS AND TREATMENT

An update for Illinois NursesElizabeth A. Peralta, MDThe Breast Center at SIUSpringfield, IL May 2011

2011 Update on these Continuing Problems: 1. What age and what

interval for screening mammography is best?

2. Is axillary dissection still necessary?

3. When does lymphedema occur and can it be cured?

Competing Recommendations USPSTF: mammography every

1‐2 years for women age 40‐69

ACS: annually starting at age 40

ACOG: mammography every 1‐2 years for women 40‐49 then annually thereafter

ACR: mammography annually starting at 40

USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade B

recommendation)

Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)

Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)

Recommends against teaching breast self‐examination (Grade D recommendation)

Th e main difference is the fine print!

USPTSF New Guidelines:

Biennial screening mammography for women ages 50‐74

Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)

Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)

Recommends against teaching breast self‐examination (Grade D recommendation)

https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm

USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade B

recommendation)

Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms

Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)

Recommends against teaching breast self‐examination (Grade D recommendation)

https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm

USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade B

recommendation)

Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)

Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older

Recommends against teaching breast self‐examination (Grade D recommendation)

https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm

USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade

B recommendation)

Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)

Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)

Recommends against teaching breast self‐examination

https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm

Comparison of Mortality Reduction-Annual versus Biennial Mammogram

ComparisonStartingAges

AverageScreeningper 1000Women

PercentMortalit

yReducti

on

Cancer DeathsAverted per 1000 Women

Life YearsGainedper 1000Women

False + per 1000Women

Unnecess--aryBiopsies per1000 Women

BIENNIAL

40‐69yo

13,865 16 6.1 120 1250 88

50‐69yo

8,944 15 5.4 99 750 55

ANNUAL

40‐69yo

27,583 22 8.3 164 2250 158

50‐69yo

17,759 20 7.3 132 1350 95

Impact of SLN trials on treatment of positive nodes in breast cancer

When is ALND not necessary, and in what circumstances is it still recommended?

Z011

Most of the patients in this trial had a low axillary tumor burden. Caution at the initiation of the study led to an attempt to assure that women with high tumor burden were not randomized to SLND alone.

Therefore, eligibility requirements specified that when surgeons felt that there was extensive axillary disease upon palpation of the nodal basin during the SLND, they were required to exclude such patients by demonstrating 3 or more involved SNs. If patients had 3 or more positive SNs, they were not eligible for randomization

Z011

Giuliano A et al. Ann Surgery 2010 252:426

The number of patients with 2 or more positive nodes identified in the ALND group was 140 (40.8%) compared with 91 (21.9%) in the SLND

Z011

Z011

SLND (n=436) ALND (n=420)

Local Recurrence 8 (1.8%) 15 (3.6%)

Regional Recurrence 4 (0.9%) 2 (0.4%)

Median Survival Not reached at 6.7yr Not reached at 6.7 yr

No statistically significant difference

So when is Axillary Lymph Node Dissection Unlikely to Provide Benefit? Tumor less than 5 cm and amenable to

lumpectomy, clinically negative nodes Combined with adjuvant radiation and

systemic therapy 1 or 2 positive sentinel nodes with no

extracapsular extension Age over 50 years, and tumor not

showing aggressive features This combination of features is

anticipated to apply to about 20 % of women with breast cancer

Identification and treatment of lymphedema after breast cancer treatment

When does lymphedema occur and can it be cured?

Secondary Lymphedema after Breast Cancer Treatment

Interstitial accumulation of protein-rich fluid, with subsequent inflammation, adipose tissue hypertrophy, and fibrosis

Onset may be months to years after treatment

Risk factors: mastectomy (versus lumpectomy), complete dissection with radiation therapy (versus sentinel node only), obesity

Early Detection of Lymphedema

Complete Decongestive Therapy

Manual lymphatic drainage Compression Exercise

Results achieved by Complete Decongestive Therapy

Results achieved by Circumferential Liposuction and Wrapping

Lymphedema Algorithm