Options in Breast Cancer Local Therapy: Who Gets What?

Today, women with primary breast cancer may consider three surgical options: breast-conserving surgery (BCS), mastectomy (MT), and mastectomy with contralateral prophylactic mastectomy (MT?+?CPM). In each case, the ipsilateral axilla is generally managed with a sentinel node biopsy and possibly an axillary lymph node dissection. BCS generally requires breast radiotherapy, except in older women having tumors with a favorable prognosis who will receive endocrine therapy. In contrast, women treated with MT generally do not require radiotherapy, except for those with large tumors or metastases to the axillary nodes. Moreover, MT and MT?+?CPM are usually undertaken with breast reconstruction. Yet, most patients today are suitable candidates for BCS, with a few relative contraindications. Thus, early pregnancy, previous radiotherapy to the breasts, active collagen vascular disease, multicentric breast cancer, large tumors (although neoadjuvant systemic therapy can often reduce tumor size), and the presence of the BRCA mutation are all relative contraindications to BCS. BRCA mutation carriers should consider MT?+?CPM because their risk of contralateral breast cancer is greatly increased. In the U.S., the use of MT for the treatment of primary breast cancer has declined in recent years, while MT?+?CPM rates have increased, and BCS rates have remained relatively stable. The underlying reasons for these trends are not fully understood. Local therapy options should be discussed with each patient in considerable detail, and more studies are needed to better elucidate which factors influence a woman's choice of local therapy following a breast cancer diagnosis.     

A systematic review of decision aids for gender affirming therapy

BackgroundTransgender and gender diverse (TGD) persons considering gender affirming therapy have to make many complex medical decisions, potentially without understanding the associated harms or benefits of hormonal and surgical interventions. Further, clinicians are often unaware of how best to communicate information to persons seeking gender affirming therapy. Patient decision aids have been developed to provide evidence-based information as a way to help people make decisions in collaboration with their clinicians. It is unclear whether such tools exist for persons seeking gender affirming therapy. The objective of our systematic review is to search for and determine the quality of any existing patient decision aids developed for TGD persons considering gender affirming therapy, and the outcomes associated with their use.MethodsWe adapted a search strategy for databases using two key concepts “decision support intervention/patient decision aid” and “transgender”. We also conducted a brief online search of Google and abstracts from relevant conferences to identify any tools not published in the academic literature. Following study selection and data extraction, we used the International Patient Decision Aid Standards instrument (IPDASi) to assess the quality of patient decision aids, and the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) checklist to assess the quality of evaluations.ResultsWe identified 762 studies; none were identified from Google or conference content. One tool met our inclusion criteria: an online, pre-encounter patient decision aid for transmasculine genital gender-affirming surgery developed in Amsterdam, translated in English and Dutch. The tool met all the IPDASi qualifying criteria, and scored a 17/28 on the certification criteria, and 57/112 on the quality criteria. The efficacy of the patient decision aid has not been evaluated.ConclusionsDespite multiple decisions required for gender affirming therapies, only one patient decision aid has been developed for transmasculine genital reconstruction. Further research is required to develop patient decision aids for the multiple decision points along the gender affirming journey.     

Adjuvant treatment for breast cancer

Adjuvant treatment for breast cancer is given following primary surgical management and aims to reduce the risk of recurrence (both local and distant) as well as improve survival rates. Radiotherapy is delivered to reduce local recurrence risk. Whole breast radiotherapy is considered standard treatment following breast-conserving surgery for invasive cancer and is also considered after mastectomy depending on pathological risk factors. Systemic therapies (such as chemotherapy, endocrine treatment and biological therapy) reduce the risk of distant metastases and improve overall survival. The decision to advise adjuvant treatment is complex (taking into account both prognostic and patient factors) and is made with the patient following a multidisciplinary team meeting. It is now common practice to employ benefit-risk calculators in the clinical setting to aid treatment decision making. Recent major advances in both systemic treatments and radiotherapy techniques have led to more personalized treatment for patients with the aim to reduce breast cancer mortality even further.     

Adjuvant treatment for breast cancer

Adjuvant treatment for breast cancer is given following primary surgical management and aims to reduce the risk of recurrence (both local and distant) as well as improve survival rates. Radiotherapy is delivered to reduce local recurrence risk. Whole breast radiotherapy is considered standard treatment following breast-conserving surgery for invasive cancer and is also considered after mastectomy depending on pathological risk factors. Systemic therapies (such as chemotherapy, endocrine treatment and biological therapy) reduce the risk of distant metastases and improve overall survival. The decision to advise adjuvant treatment is complex (taking into account both prognostic and patient factors) and is made with the patient following a multidisciplinary team meeting. It is now common practice to employ benefit–risk calculators in the clinical setting to aid treatment decision making. Recent major advances in both systemic treatments and radiotherapy techniques have led to more personalized treatment for patients with the aim to reduce breast cancer mortality even further.     

A scoping review of interactive and personalized web-based clinical tools to support treatment decision making in breast cancer

The increasing attention on personalized breast cancer care has resulted in an explosion of new interactive, tailored, web-based clinical decision tools for guiding treatment decisions in clinical practice. The goal of this study was to review, compare, and discuss the clinical implications of current tools, and highlight future directions for tools aiming to improve personalized breast cancer care. We searched PubMed, Embase, PsychInfo, Cochrane Database of Systematic Reviews, Web of Science, and Scopus to identify web-based decision tools addressing breast cancer treatment decisions. There was a total of 17 articles associated with 21 unique tools supporting decisions related to surgery, radiation therapy, hormonal therapy, bisphosphonates, HER2-targeted therapy, and chemotherapy. The quality of the tools was assessed using the International Patient Decision Aid Standard instrument. Overall, the tools considered clinical (e.g., age) and tumor characteristics (e.g., grade) to provide personalized outcomes (e.g., survival) associated with various treatment options. Fewer tools provided the adverse effects of the selected treatment. Only one tool was field-tested with patients, and none were tested with healthcare providers. Future studies need to assess the feasibility, usability, acceptability, as well as the effects of personalized web-based decision tools on communication and decision making from the patient and clinician perspectives.     

The decision-related psychosocial concerns of men with localised prostate cancer: targets for intervention and research

Purpose  To describe decision-related psychosocial issues relevant for men with clinically localised prostate cancer. Methods  Searches were conducted across three electronic databases to search the health and psychological literature for articles examining decision-related psychosocial issues for men with localised prostate cancer and their partners. Medline, PsycINFO and CINAHL databases were examined for the period from 1990 to December 2007. Results  Most men with localised prostate cancer want active involvement in decision-making. Difficulty in making the decision is common and decision-related distress may persist over time. Cancer-specific psychological distress (such as fear of recurrence but not overall anxiety) appears to be related to changes in PSA levels; and this distress influences treatment pathways. Decision support interventions are acceptable to men, improve knowledge and might reduce decision and cancer-related distress. However, the quality of intervention studies to date is low. Conclusion  Clinicians should seek to involve men and their partners in treatment decision making concurrent with decision and psychological support. There is a need for high quality randomised control trials to identify the optimal approach to decision support for men with clinically localised prostate cancer.     

合并慢性肾功能衰竭乳腺癌病人的综合治疗(附6例报告)

目的:总结合并慢性肾功能衰竭乳腺癌病人的多学科合作和个体化治疗为主的经验。方法:回顾性分析2009年1月至2010年12月间本中心6例合并慢性肾功能衰竭乳腺癌病人诊治的临床资料。结果 :6例均行根治手术,其中4例行乳腺癌改良根治术,2例行乳腺癌保乳加腋窝淋巴结清扫术。1例长春瑞滨加表柔比星新辅助化疗,1例阿那曲唑新辅助内分泌治疗。随访至2014年2月,2例因慢性肾功能衰竭死亡,余4例均未出现复发转移。结论:慢性肾功能衰竭不是乳腺癌手术及全身治疗的禁忌证。通过多学科诊疗选择个体化的手术、化疗、放疗和内分泌治疗方案、严密监测肾功能,慢性肾功能衰竭病人仍可完成乳腺癌标准治疗,同样具有治愈可能。     

Dermatosis as the Initial Manifestation of Malignant Breast Tumors: Retrospective Analysis of 4 Cases

BACKGROUND: The aim of this study was to explore the clinical characteristics, diagnosis, treatment, and prognostic factors of dermatosis associated with malignant breast tumors. CASE REPORTS: The clinical data of 4 breast cancer patients, 3 with dermatomyositis and 1 with acquired ichthyosis, were analyzed retrospectively. The 4 patients were >50 years of age, and the malignant breast tumors appeared within 5 years of the diagnosis of dermatosis. Two of the 3 breast cancer patients with dermatomyositis received a modified radical mastectomy, and because they could not afford systemic chemotherapy after surgery, only received endocrine therapy. The third patient received a simple mastectomy and axillary lymph node dissection but died of respiratory failure 2 months after the operation. The patient with acquired ichthyosis and malignant breast tumor received modified radical mastectomy, chemotherapy, radiotherapy, and endocrine therapy; no complications were observed in the postoperative period. During the 9-15 months of follow-up after the surgery, the 3 patients remained in good condition with improvement of the dermatosis symptoms and no cancer relapse. CONCLUSIONS: Malignant breast tumor screening is indicated in women with dermatomyositis or acquired ichthyosis, especially in those aged >50 years.     

Role of endocrine therapy in the neoadjuvant surgical setting

Most neoadjuvant (preoperative) therapy of breast cancer has involved the use of chemotherapy, but primary endocrine therapy has also been shown to be effective in postmenopausal women with estrogen receptor-positive tumors. Neoadjuvant therapy can reduce tumor volume, permitting surgery for otherwise inoperable tumors or allowing breast-conserving surgery rather than mastectomy for operable tumors. The preoperative treatment setting also allows for assessment and comparison of responses to different agents, which may then be used in the adjuvant therapy setting following surgery. Since tumor biopsies can be obtained before, during, and after preoperative therapy, the relationship between biomarkers and response or resistance to surgery can be investigated. In the Edinburgh Breast Unit, neoadjuvant endocrine therapy with aromatase inhibitors has been more successful than with tamoxifen. Recurrence rates following preoperative endocrine therapy and breast-conserving surgery have been acceptably low, provided that radiation therapy was also administered postoperatively. Both the probability of response to neoadjuvant letrozole or tamoxifen and the degree of tumor shrinkage increased as estrogen receptor expression increased, consistent with the results of other studies. Attempts to identify biomarkers of response to neoadjuvant endocrine therapy are under way, with early indications that reduced cell proliferation 14 days after initiation of treatment correlates with responses to tamoxifen.     

Contralateral prophylactic mastectomy improves the outcome of selected patients undergoing mastectomy for breast cancer

BACKGROUND: Risk factors for contralateral breast cancer (CBC) may indicate a benefit for contralateral prophylactic mastectomy (CPM) at the time of unilateral mastectomy for breast cancer. The purpose of this study is to evaluate the efficacy of CPM in preventing CBC. METHODS: sixty-four patients undergoing CPM and a control group of 182 patients not undergoing CPM and matched for age, stage, surgery, chemotherapy, and hormonal therapy were retrospectively compared for CBC rate, disease-free survival, and overall survival. RESULTS: Thirty-six CBCs occurred in the control group. In the CPM group, 3 CBCs were found at the time of prophylactic mastectomy, but none occurred subsequently (P = 0.005). Disease-free survival at 15 years in the CPM group was 55% (95% confidence interval [CI] 38% to 69%) versus 28% (95% CI 19% to 36%) in the control group (P = 0.01). Overall survival at 15 years was 64% (95% CI 45% to 78%) CPM versus 48% (95% CI 39% to 58%) in controls (P = 0.26). CONCLUSION: CPM prevented CBC and significantly prolonged disease-free survival. Future studies will need to address risk assessment and contralateral breast cancer prevention in patients treated for early breast cancer.     

不断提高我国乳腺癌综合治疗水平

乳腺癌是威胁女性健康首要疾病之一,手术、放疗、化疗、内分泌治疗、靶向治疗是乳腺癌治疗的重要组成部分,但单一治疗方法疗效有限.随着人们对乳腺癌认识的加深,"乳腺癌是一种全身性疾病"的理念已被广泛接受,成功有效的乳腺癌治疗应是根据患者具体情况,合理地联合应用以上各种治疗方式的综合治疗模式.随着社会文化的进步,人们对乳腺癌病...     

Multidisciplinary Management of Locally Advanced Breast Cancer

▪ Abstract: The treatment of locally advanced breast cancer is aimed at achieving long-term local control with local surgery and/or radiation therapy and at improving disease-free and overall survival through the application of systemic cytotoxic chemotherapy and hormonal therapy. Studies of local therapy alone with surgery or radiotherapy have demonstrated high rates of local recurrence and low rates of long-term survival. The application of anthracycline-based neoadjuvant chemotherapy has resulted in rates of response ranging from 72% to 97%, clinical complete responses of 12–52%, and pathologic complete responses of 4–33%. Multidisciplinary treatment with neoadjuvant therapy, followed by local surgery and/or radiation therapy, followed by additional chemotherapy, has resulted in rates of local control that exceed 80%, and 5-year survival rates exceeding 50% are not unusual. The use of anthracycline-based neoadjuvant chemotherapy in the treatment of locally advanced breast cancer is thus now firmly established. Research in the treatment of locally advanced breast cancer is needed to further define the optimal method of local therapy and the role of new agents such as the taxanes. ▪     

Current and future role of neoadjuvant therapy for breast cancer

Neoadjuvant systemic chemotherapy is a possible therapeutic approach for the treatment of locally advanced operable, primarily non-operable or inflammatory breast cancer. Neoadjuvant systemic chemotherapy is an option for breast cancer patients who would require adjuvant chemotherapy otherwise based on clinical and histological examination and imaging. The use of neoadjuvant systemic therapy in operable breast cancer is currently increasing because of its advantages that include higher rates of breast conserving surgery and the possibility of measuring early in-vivo response to systemic treatment. The timing of axillary sentinel lymph node diagnosis (i.e. before or after neoadjuvant chemotherapy) is critical in that it may influence the likelihood of axillary preservation. It is not yet clear if neoadjuvant therapy might improve outcomes in certain subgroups of breast cancer patients. Neoadjuvant treatment modalities require a close collaboration between oncology professionals, including surgeons, gynecologists, medical oncologists, radiation oncologists, radiologists and pathologists. The most important parameter for treatment success and improved overall survival is the achievement of a pathologic complete response (pCR), although the role of pCR in patients with luminal A like tumours might be less informative. Identification of patient subgroups with high pCR rates may allow less invasive surgical or radiological interventions. Patients not achieving a pCR may be candidates for postoperative clinical trials exploring novel systemic treatments.     

Breast Conservation After Neoadjuvant Chemotherapy

Background Tumor downstaging by preoperative neoadjuvant chemotherapy in patients with locally advanced breast tumors allows breast conservation in women who were previously candidates for mastectomy. Nevertheless, lumpectomy success in such cases cannot be fully achieved. The aim of this study was to create a quantitative tool for preoperative evaluation of the success of breast conservation in such patients.Methods The study population included 100 consecutive patients with stage II and III breast cancer who were designated for lumpectomy and 19 patients who were designated for mastectomy. All patients received neoadjuvant therapy. Breast-conserving surgery was offered in accordance with clinical and esthetic criteria. Demographic details and clinical, imaging, and pathologic information were collected from medical files. A decision protocol for classifying patients to lumpectomy or mastectomy was built by using the Classification and Regression Trees procedure based on preoperative characteristics.Results Three factors were found to be the main predictors for successful breast conservation: absence of diffuse microcalcifications as seen in the pretreatment mammogram, a postchemotherapy tumor size of < 25 mm, and the existence of a circumscribed lesion on mammography.Conclusions The use of these criteria as a basis for decision on the type of surgery may decrease the performance of unnecessary procedures.     

Breast cancer in women at high risk: The role of rapid genetic testing for BRCA1 and -2 mutations and the consequences for treatment strategies

Specific clinical questions rise when patients, who are diagnosed with breast cancer, are at risk of carrying a mutation in BRCA1 and -2 gene due to a strong family history or young age at diagnosis. These questions concern topics such as 1. Timing of genetic counseling and testing, 2. Choices to be made for BRCA1 or -2 mutation carriers in local treatment, contralateral treatment, (neo)adjuvant systemic therapy, and 3. The psychological effects of rapid testing. The knowledge of the genetic status might have several advantages for the patient in treatment planning, such as the choice whether or not to undergo mastectomy and/or prophylactic contralateral mastectomy. The increased risk of developing a second breast cancer in the ipsilateral breast in mutation carriers, is only slightly higher after primary cancer treatment, than in the general population. Prophylactic contralateral mastectomy provides a substantial reduction of contralateral breast cancer, although only a small breast cancer specific survival benefit. Patients should be enrolled in clinical trials to investigate (neo)-adjuvant drug regimens, that based on preclinical and early clinical evidence might be targeting the homologous recombination defect, such as platinum compounds and PARP inhibitors. If rapid testing is performed, the patient can make a well-balanced decision. Although rapid genetic counseling and testing might cause some distress, most women reported this approach to be worthwhile. In this review the literature regarding these topics is evaluated. Answers and suggestions, useful in clinical practice are discussed.     

Post‐mastectomy Radiotherapy for pT3N0 Breast Cancers: A Retrospective,Multi‐Institution Review

The role of post‐mastectomy radiotherapy for pT3N0 breast cancers remains undefined. The purpose of this study was to report institutional outcomes for women with pT3N0 breast cancers treated with and without post‐mastectomy radiotherapy. We collected data from two large tumor registries on pT3N0 breast cancers diagnosed between 1985 and 2014. Kaplan–Meier estimates were used to analyze freedom from local‐regional recurrence (FFLR), relapse free survival, and overall survival. This analysis identified 93 women with pT3N0 breast cancers. Of these, 53 received post‐mastectomy radiotherapy and 40 did not. Median follow‐up was 6.2 years and 5.3 years in the non‐post‐mastectomy radiotherapy and post‐mastectomy radiotherapy cohorts, respectively. Women not undergoing post‐mastectomy radiotherapy were more likely to be diagnosed in the 1980s and 1990s and were less likely to receive systemic therapies than women receiving post‐mastectomy radiotherapy (p < 0.05). There was a trend toward increased FFLR in the women receiving post‐mastectomy radiotherapy (p = 0.15). FFLR in the post‐mastectomy radiotherapy cohort was 98% at both 5 and 10 years. For women not receiving post‐mastectomy radiotherapy, FFLR was 88% at both 5 and 10 years. Women not receiving post‐mastectomy radiotherapy in our study had an isolated local‐regional failure rate of 12% at 10 years, despite receiving inferior systemic treatment by current standards. Local‐regional control after post‐mastectomy radiotherapy for pT3N0 breast cancers was excellent. Further research is needed to define post‐mastectomy radiotherapy indications for this patient population when receiving chemotherapy and endocrine therapy in line with current guidelines.     

Immediate Reconstruction After Neoadjuvant Chemotherapy: Effect on Adjuvant Treatment Starting and Survival

Background For patients treated with initial surgery, the safety of immediate breast reconstruction after mastectomy has been demonstrated. Some concerns exist after neoadjuvant chemotherapy because this sequence is proposed for patients with large tumors and for whom adjuvant therapies are considered cornerstones of treatment. In this study, we sought to determine whether reconstruction after neoadjuvant chemotherapy and mastectomy for large operable breast cancer affects the interval between surgery and adjuvant treatment and affects survival.Methods A single-institution retrospective analysis was performed by using the database of the Institut Gustave-Roussy.Results Forty-eight patients who had undergone mastectomy and immediate reconstruction (implant, 60%) followed by adjuvant chemotherapy were identified. They were compared with 181 patients who underwent mastectomy without reconstruction and with 32 patients who underwent mastectomy followed by delayed reconstruction (implant, 19%). No difference was found concerning the interval between surgery and adjuvant chemotherapy: 26 vs. 23 days for patients with immediate breast reconstruction and for patients treated with modified radical mastectomy followed or not by delayed reconstruction, respectively (P = .11). No difference was found concerning the onset of radiotherapy: 87 vs. 81 days (P = .22). Survival was not different in patients treated with immediate reconstruction compared with those with mastectomy alone.Conclusions Immediate breast reconstruction does not delay the starting of adjuvant therapy and has no significant effect on local relapse–free or distant disease–free survival. Additional data are needed concerning the use of flap for this indication.     

Prophylactic surgery to reduce breast cancer risk: a brief literature review

Prophylactic mastectomy reduces the likehood of developing breast cancer among women at heightened risk for breast cancer, but at significant personal cost.Women at increased breast cancer risk on the basis of hormonal history, family history and/or genetic mutation carrier status may consider bilateral prophylactic mastectomy with or without reconstruction to reduce their cancer risk and/or decrease their chances of cancer mortality. Women having received mastectomy as treatment for breast cancer may request contralateral mastectomy to decrease the chances of developing a second breast primary. The potential oncologic value of these procedures must be weighed carefully on a case -by-case basis against the operation's physical and psychological morbidity. The purppose of this literature review is to provide a practice-oriented summary of recent clinical studies attempting to address the relative risks and benefits of preventive surgery for breast cancer. Data are included regarding the psychological factors surrounding patient selection and quality of life outcomes, which become the cornerstone of patient satisfaction and acceptance. Taken together, these data support the Society of Surgical Oncology position statement regarding the proper application of prophylactic surgery for breast cancer.     

The preferred treatment for young women with breast cancer--mastectomy versus breast conservation

Paradigms on breast cancer influence surgical treatment policies. Randomised trials that compared mastectomy with breast-conserving therapy (BCT) with adequate radiotherapy showed no difference in overall survival. However, after a long follow-up, BCT was associated with a higher local recurrence rate (up to four times higher). The EBCTCG meta-analysis of 2005 concluded that one breast cancer death can be avoided for four local recurrences avoided. A minority of breast cancer patients are younger than 40 years (6.5%). When confronted with the diagnosis of breast cancer, they potentially have a long lifespan. Therefore, it is crucial to avoid local recurrences. The following factors have a positive impact on local control: mastectomy (in stead of BCT), negative surgical margins and adjuvant treatment (radiotherapy and chemotherapy). In order to provide optimal local and systemic treatment for young patients, breast cancer requires a multidisciplinary approach and the patient has to be involved in the proper treatment decision. A predictive model is needed for doctors and patients to facilitate this process.     

Facilitating Breast-Conserving Surgery and Preventing Recurrence: Aromatase Inhibitors in the Neoadjuvant and Adjuvant Settings

Breast-conserving surgery (BCS) is an attractive option for many patients with early-stage breast cancer, because it provides a better cosmetic outcome than modified radical mastectomy, while reducing surgical morbidity. In patients with large, operable breast tumors who are ineligible for BCS, neoadjuvant therapy is a useful option for reducing the tumor size and for increasing the proportion of candidates for BCS. In patients with endocrine-responsive tumors, neoadjuvant endocrine therapy with either tamoxifen or an aromatase inhibitor (AI; anastrozole, letrozole, or exemestane) provides an alternative to neoadjuvant chemotherapy. Clinical trials have demonstrated the superiority of neoadjuvant AIs over tamoxifen in achieving a clinical response and increasing the frequency of BCS. In addition, adjuvant endocrine therapy with AIs, whether used as initial therapy instead of tamoxifen, in a switching strategy after 2–3 years of tamoxifen, or as extended adjuvant therapy after 5 years of adjuvant tamoxifen, has been shown in several randomized clinical trials to improve disease-free survival, reduce distant metastases and, in some cases, improve overall survival. The availability of the AIs for effective and well-tolerated neoadjuvant and/or adjuvant endocrine therapy represents an important advance in breast cancer treatment, and surgeons should be familiar with these new therapeutic options.