The American Society of Breast Surgeons held their 17th Annual Meeting from April 13-17th in Dallas, TX. Several of breast surgeon members who were in attendance share their thoughts here. This is not meant to be a comprehensive summary of the meeting, but rather to discuss some of the highlights. Feel free to reach out to any of us if you would like additional information or clarification on any of the topics!
Survivorship and Patient-Centered Outcomes
Dr. Diane Radford
The importance of survivorship medicine as part of the continuum of cancer care was highlighted by two sessions at the 17th annual #ASBrS meeting: an all-day pre-meeting course and a session during the main meeting. Topics covered included the spectrum of survivorship medicine, cancer as a teachable moment, survivorship in special populations such as BRCA mutation carriers and young women, appropriate screening after treatment, survivorship care plans, social media in survivorship (including a special plug for #bcsm), preserving fertility during breast cancer treatment, sexuality – reestablishing intimacy, techniques to reduce lymphedema, improving service in cancer care, decision-making tools, and the collateral damage of breast cancer treatment.
In the USA there are approximately 3 million breast cancer survivors. Our measures for success of breast cancer treatment should include not only high survival rates but also excellent quality of life outcomes. It was emphasized that survivorship care plans (summarizing treatment and follow-up) are only one aspect of a robust survivorship program. Attention should also be directed to mind, body, and spirit- incorporating lifestyle medicine and integrative care.
Take away points from these presentations:
– Routine labs, scans, and tumor markers are not indicated
– Lifestyle strategies such as exercise, alcohol restriction, and maintaining ideal BMI should be encouraged, with attention paid to the optimum teachable moment time frame
– Imaging surveillance of the reconstructed breast is not recommended
– Access to fertility preserving options should be facilitated for women of child-bearing age facing treatment
– The brief sexual symptom checklist can be used to assess sexual dysfunction and the PLISSIT approach (Permission, Limited Information, Specific Suggestions, Intensive Therapy) can help guide intervention for an individual
– Nipple-sparing mastectomy patients reported better psychosocial and sexual well-being than those who underwent skin-sparing mastectomy with nipple reconstruction
– Axillary reverse mapping can reduce the incidence of lymphedema from both axillary dissection and sentinel node biopsy
– Tools such as Nurse BEDI can aid in shared decision-making between the patient and surgeon
– Participation by volunteers in studies such as the Susan Love Research Foundation Health of Women [HOW]™ Study will help to identify predictors of survival as well as consequences of therapy.
Oncoplastic Breast Surgery
Dr. Dana Abraham
While breast conservation provides equivalent survival to mastectomy in the treatment of breast cancer, the location and size of the tumor can make it challenging to preserve a normal appearance. This is a relatively new field that combines the oncologic treatment of breast cancer with the principles of plastic and reconstructive surgery. This is one of the newest directions in breast conservation. Drs. Shawna Willey (@SCWilley) and David Song (@drdavidsong) led an all day pre-meeting course on this topic. Drs. Patricia Clark (@patriciaclarkmd) and Julie Reiland (@DrJulieReiland) led a breakfast session as well. The overall concept is to avoid disfigurement of the breast. This approach takes into account the oncologic safety of various procedures, as well as the anatomic considerations and preservation of form and function. Neoadjuvant therapy (shrinking the cancer before surgery) is increasingly used to decrease the volume of tissue that needs to be removed during the lumpectomy.
Competence is divided into levels based on the degree of additional training necessary. Many of the techniques in Level 1 oncoplastics are already a part of all breast surgeons’ skill set. However, some require more advanced training in plastic surgery.
The choice of procedure is based largely on the location of the tumor and the size and shape of the breast. The composition of the breast with regard to density is also important. Breast tissue that is fatty replaced does not tolerate rearrangement as well as dense tissue. Traditionally, tumors located in the lower breast were associated with significant ‘bird’s beak’ deformity. Now, by careful placement of incisions, mobilization of the remaining tissue to replace lost volume, and moving the nipple up, we can avoid this. Many times, a procedure on the opposite side is also required to restore symmetry. The goal is to keep the nipple-areolar complexes even and maintain a normal shaped breast mound.
Breast surgeons with Level 2 training are performing traditional breast reductions and breast lifts. In general, we try to avoid any future surgery on a radiated breast. For this reason, women who present with preexisting symptoms of back and neck pain due to their large breasts benefit from having their symptoms addressed prior to the radiation therapy that is associated with breast conservation. The oncologic principles of clear margins and axillary staging are included. Significant ptosis can also be corrected.
This is a very exciting new direction in the management of breast cancer. As more breast surgeons learn the concepts and techniques, we will continue to optimize the cosmetic outcomes of our patients.
Nipple Sparing Mastectomy (NSM)
Dr. Howard Karpoff
NSM is a total mastectomy with preservation of the nipple/areola and breast skin. Dr. Tina Heiken (@TJH0828) discussed the indications, risks and benefits.
Mastectomy rates are increasing overall & bilateral mastectomy rates are increasing as well – better cosmetic outcomes due to the increased utilization is likely a contributing factor. In addition to an improved cosmetic outcome, a 2nd procedure for nipple reconstruction is not needed. While often the overall reconstruction requires more than one procedure, it can sometimes be performed as a one stage procedure.
While there are few long term studies on NSM for risk reduction, the acceptance and performance of NSM has increased over time, and NCCN guidelines do support the consideration of NSM in selected patients who are candidates for prophylactic mastectomy due to their high risk for breast cancer (BRCA, TP53, pTEN, CDH1, PALB2 mutation carriers).
Initially, patient selection criteria for NSM were stringent and only low risk patients chosen such as those with small tumors, >2cm from the nipple / areolar complex (NAC), and negative lymph nodes. Dr. Heiken stated more recent studies indicate NO association between NAC removal with tumor size, distance from nipple, multi centricity, age or preoperative MRI. NSMs are contraindicated for patients with inflammatory breast cancer Paget’s disease, nipple involvement with cancer, and breast cancer presenting with nipple discharge. Caution and discretion are advised for multicentric breast cancer , node + disease or skin retraction, although response to neoadjuvant therapy should be considered and some of these patients may be good candidates for NSM.
Ideal candidates are women who are young and otherwise healthy, small/medium breasts, minimal ptosis and non smokers. Smokers not good candidates for NSM – their risk of healing complications and nipple necrosis related to NSM and breast reconstruction in general is increased. It is recommended to use caution in patients who are obese, have a history of prior radiation therapy or breast surgery, have very large breasts, ptotic breasts, or in those patients with diabetes and other medical problems.
In a systematic review of 27 studies including 3331 NSM cases, the overall complication rate was 20-35% including 8.8% with some necrosis of the NAC, 2% NAC loss, 9.5% flap necrosis and 3.9% implant loss. In studies of cancer patients with >5 years of follow up, local recurrence rates are reported to be 2-12%, and nipple areolar complication rates are reported at 1-4%. In studies of patient satisfaction, 66-89% like appearance; 56-61% approve of position of the nipple. Nipple sensation rates are low. Decreased satisfaction is noted in patients with greater body mass index (BMI), larger implant / tissue expander volume, patients who required post-mastectomy radiation, and those who underwent unilateral (one side) reconstruction.
Dr. Jill Dietz (@DrJDietz) discussed techniques for NSM. She also noted that proper patient selection is important. She described how to get started including equipment and technical issues. Some pointers included avoiding a transareolar incision. Suggestions for incisions include radial, inframammary (avoiding the superficial epigastric vessels), vertical incision in patients with prior reduction surgery, and skin reduction for patients with ptosis and large breasts.
Dr. James Jakub reported on a multi-institutional study assessing the oncological safety of prophylactic NSM in BRCA patients looking at 551 risk-reducing NSM in 348 patients with a median follow up of 34 months; there were no cancers that developed in these patients.
Benign Breast Disease, and Debate on DCIS – Is it Cancer?
Dr. Michele Carpenter
Breast Pain is very common and mostly associated with reproductive life and hormonal changes both intrinsic and extrinsic. Most get better or feel better with reassurance and better fitting undergarments. Doctors should treat beyond that with low risk treatments first and progress to prescriptive medications as last resort.
Nipple discharge that is spontaneous and clear or bloody is the kind to be worked up. Fluid cytology not recommended. Cancer is seen in less than 20% of cases. Duct excision is usually indicated.
Breast abscesses both lactational and nonlactational are treated with aspiration first and I&D later or when close to the skin surface and should be followed until resolved. Biopsies may be in order if worrisome signs evident. Chronic abscesses with fistulas should have the fistula tract removed through radial incision.
Granulomatous mastitis is a benign condition that is hard to treat. In Asia and the Middle East it is due to TB and echinococcus and in the USA, not infectious. It is usually presenting with pain, redness, inflammation and draining areas and sometimes nipple discharge. The reasons why it happens are unclear and the treatment is unclear as it rarely grows bacteria and it responds sometimes to antibiotics and sometimes to immunosuppression (steroids and methotrexate or topical steroids). You can do nothing or use antibiotics or surgery or steroids or both steroids and antibiotics but do try to look for corynebacterium. Don’t forget to rule out cancer if needed especially if the patient does not improve.
Benign biopsies may show precancerous changes. There is a possibility that with a needle biopsy alone that with larger operative biopsies, there may be cancer. Atypia 20%, FEA or columnar cell lesion with atypia 3-10%, Radial scar 7.5%, radial scar with atypia 26%, papillomas with ADH or FEA 33%. Antiestrogens reduce the risk of malignancy, biopsy and benign breast disease but with side effects.
Is DCIS Cancer? NO
– DCIS is abnormal increase if epithelial cells inside the duct
– Some but not all becomes invasive cancer
– Survival benefit of breast surgery for low grade DCIS was small than for higher grades.
– The definition of cancer is when they spread into the surrounding tissue. Cancerous tumors spread into the surrounding tissue and some travel through lymph and blood. Therefore DCIS is not cancer and we are over treating DCIS.
Is DCIS Cancer? YES
– DCIS can progress to invasive cancer and some who have DCIS also have invasive cancer and some patients recur after treatment and some with DCIS ultimately die from breast cancer.
– For every screen detected case of DCIS, there was one fewer invasive interval detected cancer in the next 3 years.
– 11% having mastectomy for DCIS and 9% patients at completion mastectomy for DCIS got upstaged.
– What we DO NOT know is who will progress to invasive cancer and which patients who have DCIS actually have invasive cancer and which ones actually recur after treatment.
– Management of DCIS needs to be personalized and we need to develop better predictors of outcome through clinical trials.
Surgical Treatment of Local recurrences and Stage 4 breast cancer
Dr. Rebecca Alleyne
Two sessions covered what to do when an invasive cancer returns in the same breast. Dr. Sarah McLaughlin discussed risk factors for invasive cancer recurrence. Not getting radiation, aggressive tumor biology and not getting targeted therapy when appropriate (e.g. a patient with an ER positive tumor who doesn’t get hormonal treatment), larger tumor size and young patient age all increase the risk of recurrence.
Margins remain very important in preventing local recurrence. Clear margins lead to a 2.5 fold decrease in local recurrence. Clear margins for invasive cancer are defined as no tumor on ink. Local recurrence rates are less common now than in the past, most likely due to better targeted therapy
Dr. Mahmoud El-Tamer discussed what to do when breast cancer comes back locally (in the breast, skin or chest wall) after mastectomy and lumpectomy. After mastectomy patients should know what to look for- 96% present with a mass. This can show up as a nodule under the skin or a mass growing up from the skin. Other signs include redness, skin ulcers, and nipple ulcers if the nipple was spared. These should be worked up with imaging (usually ultrasound or MRI), biopsy (needle biopsy, skin punch or excision) and a metastatic workup. Surgical treatment should be wide excision. Wide excision can be done after reconstruction. 81% of TRAM reconstructions could be spared in one study. Implants needed removal and replacement with tissue expander. After lumpectomy with radiation therapy surgical treatment of a breast recurrence should be mastectomy. Repeat lumpectomy has a high recurrence rate.
Dr. David Brenin talked about what to do with the axillary nodes after a recurrence- if the lymph nodes are clinically positive (nodes your doctor can feel) an axillary dissection is recommended. If there are no clinically positive axillary nodes there’s no standard for treatment. A sentinel node biopsy is an option. The overall success rate is 65% in repeat sentinel node biopsy after a local recurrence. This is lower in patients who had prior axillary dissection. Axillary dissection is an option also but has high morbidity. No surgical treatment in the axilla is a third option; systemic therapy and radiation including axillary radiation can be used without surgery.
Dr. James Jakub discussed breast surgery for patients who have stage 4 breast cancer when diagnosed. 3 to 6 % of breast cancer patients present with stage 4 disease. The NCCN guidelines recommend systemic therapy first, and surgery for palliative treatment. Studies showed half of patients presenting with Stage 4 breast cancer get surgical removal of the primary tumor. Death risk was lowered by 40% in patients undergoing breast surgery for stage 4 cancers, but there was some selection bias throughout the studies evaluated. The patients in the studies had smaller tumors, fewer metastases and fewer comorbidities. Referral bias was a likely factor- patients considered for surgery with stage 4 disease were younger, had more bone only metastases, were more often Caucasian, were more likely to be insured and had access to more health care.
Dr. Nimmi Kapoor
An excellent session on Friday broadly titled, “Genetics,” covered many topics including assessing personal risk, hereditary multi-gene panel testing, and management of various gene mutations.
Dr. Amy Degnim from Mayo Clinic reviewed all the available and up-coming risk-prediction models for assessing personal lifetime risk of breast cancer. Many of these models, such as Gail and IBIS, incorporate personal factors, family history, and history of benign breast disease to estimate future risk of breast cancer and can be used to determine MRI eligibility. Some models, such as IBIS and BRACAPRO, can also estimate chance of carrying a gene mutation in BRCA1 or BRCA2. Newer models such as BCSC BBD will also incorporate mammographic breast density into risk estimates.
Genetic counselor Sara Pirzadeh-Miller from UT Southwestern Medical Center reminded us of the importance of genetic counseling, especially in this current era of panel testing and many newer, less understood gene mutations. Mayo Clinic scientist Dr. Fergus Couch discussed some of the fascinating science behind discovering the cancer-association of genes other than BRCA1/2, such as PALB2, CHEK2, and ATM. The risk of breast and other cancers associated with each gene mutation, and even each type of mutation within the same gene, will be different; so surveillance and intervention should be tailored to the specific mutation.
Dr. Anees Chapgar (@AneesChagpar) from Yale reviewed surgical interventions for women with BRCA1/2 mutations. She reviewed the safety data for nipple-sparing mastectomy in this group of women along with the benefits of oophorectomy in both reducing risk of ovarian cancer as well as breast cancer. Moreover, she reminded us that not all women that carry mutations will want to have surgery, so effective screening will be important for them.
The last segment of the Genetic Risk session switched from hereditary genetic risk to tumor genomics. Dr. Lee Wilke (@LeeWilke) from University of Wisconsin discussed tumor biology and how identifying various mutations within tumor cells may help direct treatment. She reviewed several prediction tools that can assess risk of recurrence such as Oncotype, Mammaprint, PAM50, and Breast Cancer Index. She also touched upon “whole tumor sequencing” and a personalized approach to understand individual tumor mutations and targets for treatment. There are numerous trials opening that will further our approach to personalized treatment of cancers.
Dr. Kimberli Cox
This year we were treated to 3 talks plus a quick shot presentation and 1 “How I Do It” video on neoadjuvant treatment which were much more clinical than in the past.
Dr. Richard White from Carolinas Medical Center talked about how neoadjuvant chemotherapy (NAC) impacts breast surgery options. He referenced several large trials which showed no survival benefit to NAC, no change in local regional recurrence (LRR) but that triple negative breast cancers (TNBC) respond better to NAC; there was no evidence that lobular cancers had a poorer pathologic response rate so NAC should be considered safe and may help convert to lumpectomy. Surgically he noted that there was no difference in post operative complications with NAC and that recurrence rates in the nipple after nipple sparing mastectomy were nil in a UCSF review. Mastectomy rates were still high after NAC, 40% because of patient preference and 28% due to extent of disease. Most interesting (to me anyway) was the discussion about whether or not we need to remove all the previously involved tissue after NAC. MRI has the best sensitivity to assess how much tissue is still involved and his contention was, based on pathologic studies, that only the tissue that still appeared to be involved needed to be removed; the question of how wide of margins are needed is still up in the air.
Dr. Abigail Caudle of MD Anderson discussed the management of the axilla after NAC. She argued that ultrasound +/- biopsy assessment of the axilla prior to NAC is vital and that marking clips should be placed at the time of any node biopsy. She discussed her work in Targeted Axillary Dissection (TAD) in which they place a radioactive seed in the clipped node and then perform a dual tracer (Techitium 99 and blue dye) sentinel lymph node biopsy after NAC. This is done because of data showing that clipped/previously biopsied nodes are not always obtained during axillary surgery. Using this technique and removing more than 3 nodes reduced the risk of false negative results (not finding disease in the axilla when it was still present) in patients who had positive nodes prior to NAC. She noted that there is no long term data on omitting axillary node dissection in patients who become clinically node negative after NAC but there are two on-going trials to compare axillary radiation to radiation + axillary node dissection in terms of recurrence rates and disease free survival.
Also from MD Anderson, Dr. Fraser Symmans reported on standardization of assessing pathologic response after NAC. He showed lots of very complex slides and commented on the difficulty of assessing response but that the final recommendations are that pathologists need to comment on the degree of pathologic complete response (pCR) vs residual disease, residual cancer burden (based on breast and axillary disease, if any, remaining after NAC; can use MD Anderson calculator) and current AJCC guidelines.
Finally, while not focused on neoadjuvant treatment, Dr. Lisa Newman of University of Michigan discussed the rates of TNBC and Her-2 positive tumors in African American women and women of Africa. She showed that rates of TNBC were much higher in Ghanaian women (western Africa) and Her-2 positive more common in Ethiopian; because of slave trade routes, this may explain why African American women are more likely to have TNBC. There are interesting implications for targeted molecular treatments, including NAC.
Male Breast Cancer
Dr. Deanna Attai
I was thrilled to have Dr. Oliver Bogler (@obogler) participate in the program this year. Dr. Bogler is a cancer researcher at MD Anderson, and a male breast cancer survivor. He spoke during the clinical trials session on advancing male breast cancer through clinical trials. His post on the subject is here. He added a unique perspective to the conference, and his talk and the information provided was very well received.
Dr. Deanna Attai
Dr. Laura Kruper (@LauraKruperMD) started the session discussing Underserved Populations including Racial, Ethnic and Socioeconomic Disparities. An Institute of Medicine report has noted that “racial and ethnic disparities in healthcare persist even when controlling for patients’ insurance status and income”. For example, she noted that while the incidence of breast cancer is similar for both non-Hispanic White and Black women, the mortality rate for Black women is higher. African American women are also more likely to present with larger tumors and lymph node + disease.
Poverty and lower education levels are associated with decreased survival – contributing factors include delays in clinical presentation, delays in follow up on abnormal mammograms, inequities in the quality of care, and access to screening. Patients covered by Medicaid insurance and those of low income were more likely to undergo mastectomy compared to breast conserving surgery. African American, Hispanic and Asian women were less likely to undergo post-mastectomy reconstruction as were women covered by Medicaid insurance.
Dr. Kruper noted that chemotherapy is more often given to African American, Hispanic and Asian women, mostly due to advanced stage or triple negative and Her2 positive subtypes. African American women have a lower pathologic complete response (pCR) rate to neoadjuvant chemotherapy compared to non-Hispanic White women. While federal agencies require that women and minorities be represented in clinical trials, <10% of patients enrolled in SWOG trials are African American, and participation in all cancer clinical trials is disproportionately low for racial and ethnic minorities.
Dr. Benjamin Anderson, from the Fred Hutchinson Cancer Research Center and the University of Washington, spoke on the global burden of breast cancer. Discussing breast cancer in the United States, he noted that early detection works when followed by appropriate treatment; to save lives, screening programs must be linked to timely and effective treatment. Worldwide, it is projected that there will be 19.7 million newly diagnosed breast cancer cases over the next decade, 10.6 million of which will occur in low / middle income countries (LMC). It is estimated that of the 5.9 million women who will die due to breast cancer over the next decade, 3.9 million will be in LMC, and >1.5 million deaths will be premature and potentially preventable.
He noted that in the US, 90% of newly diagnosed breast cancer patients present with DCIS or stage I-II disease. In India, 76% present with locally advanced or metastatic (Stage III or IV) breast cancer. He noted the importance clinical breast exams, especially in LMCs. He also addressed challenges such as pathology assessment. While in the US we have migrated from fine needle aspirations (FNA) to core biopsies in order to obtain more tissue to assess receptors and perform subtype analysis, he noted that even the most inexpensive core biopsy device is cost prohibitive ($30-60 for a single use) in LMCs. A FNA can be performed for <$5 and once cytopathology evaluation is integrated into the system, results are available very quickly. He noted that programs such as the Fred Hutchinson Breast Cancer Initiative 2.5 may improve outcomes, but they require collaboration among clinical, public health, and political communities.
Dr. Lisa Newman discussed the impact of race and ethnicity on tumor biology and outcomes, and is covered in the section by Dr. Kimberli Cox (above).
Dr. Rhonda Henry-Tillman from the University of Arkansas discussed breast cancer programs in the developing world. She focused on her personal experience in Zambia, Africa, and described the program that has been put in place at the University Hospital there. Since opening in 2007, over 8000 patients have been treated (various types of cancers). Mammography is not widely available, but ultrasound is; most breast cancer patients present with locally advanced disease. She has been instrumental in implementing a breast cancer early detection, training, and village-based education program. She has educated local physicians on the use of ultrasound, performance of breast conservation and oncoplastic techniques, and sentinel node biopsy. She noted that our focus must be action – there are so many programs that are cost-effective that if implemented in LMCs can result in significant survival improvements. She is a perfect example of how just one person can make a difference!