Evaluation, Surgical Treatment, and Post-Treatment Surveillance of

Early Stage Breast Cancer: National Guidelines

Deanna J. Attai, MD, FACSAssistant Clinical Professor of Surgery

David Geffen School of Medicine at UCLA

No Financial Disclosures

Breast Cancer Statistics

•Most common type of cancer among women (excluding skin cancer)

•Second most common cause of cancer deaths among women

•1 in 8 women, 1 in 1000 men •Women: 200,000 new cases, 40,000 deaths/year•Men: 2360 new cases, 450 deaths/year

• Incidence and survival vary depending on race, ethnicity, socio-economic status

Breast Cancer Staging

•Stage 0 – Ductal carcinoma in-situ / DCIS

•Stage I – Tumor <2cm, negative lymph nodes•Stage II – Tumor 2-5cm OR spread to lymph nodes

•Stage III – Tumor >5cm, OR fixed to skin / muscle, OR matted nodes, OR internal mammary nodes

•Stage IV – Metastatic disease (liver, lung, bone, brain most common)

Preoperative Workup

• History and physical exam• CBC, platelets, LFT, AlkPhos• Diagnostic bilateral mammogram, consider ultrasound• MRI optional• Pathology review, ER/PR and Her2/neu status• Genetic counseling if at risk for hereditary cancer• Fertility counseling if premenopausal• Assess for psychological distress

Preoperative Workup

•For clinical stage I-IIB additional studies ONLY if directed by signs/symptoms:

•Bone scan localized bone pain or AlkPhos•Abdomen/pelvis CT, MRI, PET/CT elevated LFT, abdominal symptoms, abnormal PE

•Chest CT pulmonary symptoms

•Tumor markers NOT recommended

Team Approach

Breast Cancer Surgery

• First described 1500s• General Anesthesia 1840s• Halsted Radical Mastectomy:

1894-1960-70’s

• Halsted died in 1922

CANCER

LYMPH NODE

FISHER THEORY

LUNGS

LIVER

BONE

BLOOD STREAM

Dr. Bernard FisherNSABP B04 Enrollment 1971-1974

www.NSABP.edu

Fisher B et al. N Engl J Med 2002;347:567-575.

NSABP B04 Results

• Preservation of the pectoral muscle new standard of care• 2 step procedure should be performed

NSABP B06 Enrollment 1976-1984

www.NSABP.edu

NSABP B06 Results

Fisher, et al N Engl J Med,Vol. 347, No. 16 · October 17, 2002

NSABP B06 Results

• No difference in survival at 20 years

• Lumpectomy without postoperative irradiation higher local recurrence 39.2% vs. 14.3%

• BCS New standard of care for Stage I/II

Fisher, et al N Engl J MedVol. 347, No. 16 · October 17, 2002

Breast Surgery

• May need re-evaluation due to national increase in mastectomy rates for early stage breast cancer

• NCCN does not indicate preference for surgery

Surgical Technique

“The NCCN panel accepts ‘no ink on tumor’ from the 2014 SSO-ASTRO Consensus Guideline on Margins”

Surgical Margins

Surgical Margins

“The ASCO review panel endorses the SSO/ASTRO recommendations with qualifications… reinforces and amplifies the guideline authors’ call for the monitoring of outcomes at the institutional level”

Importance of Axillary Lymph Node Status

• Node status determines stage, predicts outcome• Node status influences adjuvant therapy decisions:

- Chemotherapy, anti-estrogen therapy- Drug choice, dose, combination- Radiation therapy

• Positive nodes in ~ 5-30% clinical stage I & II patients• High rate of lymphedema, paresthesias, shoulder

dysfunction. No benefit in node-negative patients

History of Axillary Lymphadenectomy

• Petit 1774 • Pancoast 1884 • Halsted 1895 • Patey 1948 • Krag, Morton, Giuliano, Tafra, Ross, Reintgen, 1990s

- Sentinel Node

Development and Validation of Sentinel Node Biopsy Technique• Morton, D, et al. Technical Details of Intraoperative Lymphatic Mapping for Early Stage Melanoma Arch Surg. 1992;127(4):392-399

• Krag DN, et al. Surgical resection and radiolocalization of the sentinel lymph

node in breast cancer using a gamma probe. Surg Oncol 1993;2:335-339

• Giuliano AE, et al.Lymphatic mapping and sentinel lymphadenectomy for breast

cancer. Ann Surg 1994;220:391

Sentinel Lymph Node Dissection

Sentinel Node BiopsyNSABP B32; Enrollment 1999-2004

Mamounas, EP Clin Med Resv.1(4); 2003 Oct

NSABP B32 Results• 5,611 patients, 80 sites, 232 surgeons• SN Identification rate 97%• 26% had positive node• 9.7% false negative rate; less common with >1SN, more

common if excisional biopsy performed first• OS, DFS, Regional Control statistically equivalent

• SNB alone is safe, appropriate, and effective in patients with clinically negative nodes

• Lumpectomy AND mastectomy patients

Positive Sentinel Node (891 patients)Axillary

Dissection (445)

No axillary

Dissection (446)

Positive Sentinel NodeACOSOG Z0011 Trial

• No difference in OS or DFS• 70% vs. 25% wound infections, axillary seromas, paresthesias• Lymphedema 13% vs. 2%; longer term after SNB 5-8%

Giuliano AE, et alJAMA 2011;305:569-75

ACOSOG Z0011 Change in Practice

Breast Conservation Patients•No intraoperative frozen section•No ALND if 1-2 positive nodes

Other Patient Populations?•Mastectomy, APBI, Neoadjuvant Therapy•AMAROS Trial - Radiation shown to be as effective as AXND, lower morbidity

Surgical Axillary Staging

Surgical Axillary Staging

• Women without SLN metastasis should not receive ALND• Women with 1-2 metastatic SLNs planning to undergo breast

conserving surgery with WBR should not undergo ALND

Surgical Axillary Staging

• Sentinel node biopsy for Stage I-II patients• NCCN includes Stage IIIA• Lumpectomy and mastectomy

Immediate Reconstruction•Most patients are a candidate unless locally advanced or inflammatory cancer

• Implant or free flap (fat and skin); less commonly muscle flap used

•Skin-sparing / NAC-sparing mastectomy with reconstruction can result in minimal scarring

•Collaboration with breast surgeon, plastic surgeon, medical oncologist, and radiation oncologist is crucial for optimal results

Federal Legislation

•Women’s Health and Cancer Rights Act of 1998

• Insurers who cover medical / surgical treatment for breast cancer must cover:

• Ipsilateral mastectomy reconstruction•Surgery / reconstruction of other breast for symmetry•Prostheses and lymphedema management

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Reconstructive Surgery

Reconstructive Surgery

• All women should be educated about reconstructive options • Oncoplastic techniques can increase breast conservation• NAC-sparing may be an option in patients who are carefully

selected by experienced multidisciplinary teams

Reconstructive Surgery Options

• Tissue expander -> Implant• Direct to implant• Latissimus flap• Free flap (DIEP and others)• Oncoplastic reconstruction • Fat grafting after lumpectomy or mastectomy

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Nipple Sparing Mastectomy

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Target enrollment: 2000 cases

NSM / Implant

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NSM / DIEP

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Lumpectomy / Oncoplastic Reduction

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Post-treatment Surveillance

Post-treatment Surveillance

• Regular history, PE and mammography recommended• Physical exam

• q 3-6 months x 3 years• q 6-12 months years 4-5• Annual after year 5

• Breast conserving surgery• Post-treatment mammogram no earlier than 6 months after radiation, or at 1 year after initial study

• Resume annual imaging unless otherwise indicated

Post-Treatment Surveillance

•NOT RECOMMENDED for asymptomatic patients:•CBC, chemistry panels, LFTs•Tumor markers CEA, CA 15.3, CA 27.29•Breast MRI•Chest x-ray•Liver ultrasound•Pelvic ultrasound•Chest / Abdomen / Pelvis CT, MRI, PET/CT

References

•National Comprehensive Cancer Network• www.NCCN.org

•National Accreditation Program for Breast Centers• https://www.facs.org/quality%20programs/napbc/standards

•American Society of Clinical Oncology• http://www.instituteforquality.org/practice-guidelines

•The American Society of Breast Surgeons• https://www.breastsurgeons.org/new_layout/about/statements/index.php