The American Society of Breast Surgeons held their 16th Annual Meeting from 4/29/15-5/3/15 in Orlando, Florida – approximately 1400 were in attendance. The following are thoughts and highlights from some of the surgeons who attended the meeting. The full program can be viewed here and the official proceedings, which contains the abstracts, can be viewed here. This post gives you the thoughts and impressions of Drs. Deanna Attai, Michael Cowher, Diane Radford, and Joseph Contino.
Perspective From a Breast Cancer Survivor:
While I have heard @stales speak before, I was PROUD that the Society opened the meeting with a patient’s perspective. I have been to several other national meetings, and in all the common debate, statistics, and banter over the controversies in our field, the ‘patient impact’ of all of this sometimes is silent. While @stales’ eloquence is well known to the #BCSM community, it was a gem to have her words open the meeting. ~MSC
Breast Cancer in The Very Young:
Dr. Ann Partridge spoke on this relatively uncommon condition; approximately 1 in 200 women under the age of 40 are diagnosed with breast cancer. Breast cancer in young women tends to be a more aggressive disease, often more advanced at presentation, and is associated with higher rates of recurrence and mortality. However, the effect of age varies by tumor subtype. There is a higher proportion of triple negative and Her2/neu positive disease in younger women. She made several points:
– Age is not a contraindication to breast conservation
– Age not the only criteria to take into account when deciding if chemotherapy needed; tumor factors play an important role
– Fertility preservation is a very important to be discussed prior to initiating treatment
– Young women are more likely to suffer physically and psychosocially – study and support is needed. ~DJA
Dr. Ann Partridge’s session “Breast Cancer in the Very Young” got a lot of eyebrows raised in the room, and online, when she asked “if we are over-treating women because of young age?” Again, this is not news, but she reminded us that contralateral prophylactic mastectomy has no influence on overall survival, and presented data showing that there is no increased risk for young women who get pregnant after a breast cancer diagnosis. She spoke of a randomized controlled trial of anti-endocrine therapy ‘pause’ for young survivors who wish to get pregnant, the POSITIVE trial. There was a lot of ‘digital applause’ for this session. ~MSC
Screening Considerations in the Elderly:
Dr. Sara Javid discussed that the goal of screening in the elderly is to prevent the development of advanced cancer through early detection and treatment while at the same time minimizing overdiagnosis. We know that the accuracy of mammography increases with age (as the breast density decreases). The risks of screening in older women include include false positive results (6-10%) and overdiagnosis (1-10%). There is no data showing that mammography in women over the age of 75 improves breast cancer survival as no studies have been done in this population; only one study included women 70-74 with inconclusive results.
The recommendations from the various organizations regarding mammographic screening in older women are not consistent. There is no clear upper age limit, but rather a “co-morbidity limit” (other medical problems that impact survival). Early detection will only improve survival for a woman who would die of breast cancer before something else. It is a balancing act of risks and benefits, there are challenges in defining what is “elderly”, and in and predicting life expectancy. An individualized approach focusing on physiologic not chronologic age and other medical problems is recommended. ~DJA
Breast Cancer During Pregnancy:
Dr. Mary Gemignani covered breast cancer during pregnancy, defined as a diagnosis of breast cancer during the gestational or lactational phase, or within one year of pregnancy. Breast cancer is the 2nd most common cancer associated with pregnancy (cervical cancer is most common); approximately 0.2 – 3.8% of all pregnancies. The age of the woman during pregnancy plays a significant role – for women younger than 40 the rate is 1 in 210; for women age 40-59 the rate is 1 in 26.
It is not uncommon for there to be a delay in diagnosis due to physical changes in the breast associated with pregnancy. Ultrasound is the preferred method of imaging workup. Anesthesia concerns during pregnancy include increased risk of blood clots, potential for hypotension (low blood pressure), aspiration, and the potential for premature labor.
Surgical treatment is recommended to be performed during the late late 1st / early 2nd trimester. An alternative approach is to treat with neoadjuvant chemotherapy (chemotherapy is contraindicated before 10 weeks gestation, and it is suggested to avoid within 3 weeks of delivery). Tamoxifen during pregnancy is associated with an approximately 20% risk of birth defects and should be avoided.
Dr. Gemignani’s conclusion was that a multidisciplinary team approach is necessary along with a discussion of patient’s desires. After the 1st trimester, surgery and/or chemotherapy is feasible and safe.
In her session on young women, Dr. Partridge mentioned an ongoing clinical trial assessing the safety of interrupting therapy for pregnancy, the POSITIVE Trial. ~DJA
Male Breast Cancer:
Dr. Henry Kuerer covered male breast cancer, noting that it accounts for <1% of all breast cancers in the US; ~2200 cases/year, with a mean age of 67. The most common subtype is invasive ductal, ER/PR+; triple negative is very rare and only 12-16% of male breast cancers are Her2/neu+.
As in women, most men have no specific risk factors. Increased risk is associated with family history, genetics, Klinefelter’s Syndrome (XXY chromosomes), increasing age, radiation exposure, obesity, and possible environmental exposures. Approximately 15% of men with breast cancer have a family history. Any male patient with breast cancer has a 4-14% likelihood of carrying a BRCA2 mutation. The lifetime risk of breast cancer for a healthy male BRCA2 carrier is approximately 8%. Genetic counseling and testing should be offered to ALL male breast cancer patients.
Men are more likely to present with advanced stage disease. The most common symptoms include a painless lump, nipple retraction and/or bleeding. Workup should include mammogram, ultrasound, and core needle biopsy. Due to more advanced stage at diagnosis, men may require neoadjuvant (before surgery) chemotherapy. Surgical options include mastectomy +/- reconstruction (most often lipofilling), breast conservation in selected patients, and sentinel node biopsy. Recommendations for adjuvant therapy are similar to women but unfortunately there are no prospective studies. Aromatase inhibitors controversial – tamoxifen is most commonly used although just as in women, side effects interfere with compliance.
The role of mammography for post-treatment surveillance is unknown but it is reasonable to do if lumpectomy is performed. Men treated for breast cancer have an approximately 12.5% risk of other cancers – GI, prostate, pancreas, non-melanoma skin cancer – so they require ongoing surveillance.
Dr. Kuerer closed by mentioning the International Male Breast Cancer Program which consists of 3 parts – retrospective analysis, prospective international registry, and clinical trials in male breast cancer patients. ~DJA
I enjoyed the “debate” between Drs. Terry Mamounas and Monica Morrow regarding if “Neoadjuvant Therapy is the Standard of Care.” I have come to realize that like many debates at professional meetings, both sides would define the premises to their liking, but did note that the usually ironclad (in her arguments) Dr. Morrow did make significant concessions to the neoadjuvant (chemotherapy before surgery) argument. Before this, however, Dr. Mamonas described the benefits of having chemotherapy upfront: allowing breast conserving therapy in women not candidates for such without tumor shrinkage, and documentation of complete pathologic response (pCR – no viable tumor at surgery after chemo). Dr. Morrow then reminded us that while a survival benefit for patients undergoing neoadjuvant chemotherapy compared to those having traditional adjuvant chemotherapy has not been demonstrated, (http://www.ncbi.nlm.nih.gov/
Dr. Pat Whitworth (@WhitworthMD) discussed the immense unmet need for genetic testing. He informed us that of over 220,000 unaffected BRCA1/2 mutation carriers in the US, only 5-6% have been identified and informed. Over 35,000 breast cancer patients harbor deleterious BRCA1/2 mutations — 30% have been identified and informed. Dr. Whitworth quoted the esteemed scientist Mary Claire King PhD, discoverer of the BRCA1 gene and winner of the 2014 Lasker Award, who said, “To identify a woman as a carrier only after she develops cancer is a failure of cancer prevention”. Thus we surgeons need to continue our desire for increased knowledge in this area, and be not afraid of new technology — the relatively new technology of panel testing. Of the harmful mutations found on breast cancer panel testing, more than 50% are in genes other than BRCA1 and BRCA2.
Dr. David Euhus’ talk on “Mutations Beyond BRCA” expanded on those other genes. With the loss of Myriad’s patent on BRCA 1 and 2 testing and the availability of genetic panel tests from Myriad, Ambry, GeneDx and others, we are seeing many other genes mentioned in reports. The most common harmful mutations found other than BRCA 1 or 2 on Myriad MyRisk panel testing are CHEK2, ATM, PALB2, BRIP1, BARD1, NBN, and TP53, whereas on Ambry Genetics BreastNext panel they are CHEK2, ATM, PALB2, PTEN, RAD50, RAD51C, and MRE11A.
Dr Euhus reminded the audience that all these genes have variable penetrance and therefore variable associated risk (see figure). He concluded that there was only a 5‐7% chance that something useful will be found beyond BRCA1 or BRCA2. This does not negate panel testing however, but only reinforces Pat Whitworth’s quote from Dr. Kevin Hughes, “Doctors who do genetic testing should know what they are doing.” And that’s why the annual meeting of the American Association of Breast Surgeons #ASBrS is so helpful — keeping us informed and enabled. Better providers and advocates because of what we learn. ~DMR
Joy Larsen Haidle (@JoyLarsenHaidle) is the President of the National Society of Genetic Counselors and spoke in the session with Dr. Whitworth. She explained that 5-10% of all breast cancer is hereditary, and if patients are identified as mutation carriers before they develop cancer, this will lead to increased screening, risk-reducing surgeries or other treatments, as well as behavior modifications. In addition, family members who may be at risk can be identified. She covered the issues of panel testings, noting that many mutations can now be identified, but not all of these are actionable (require treatment); in addition, she stressed that despite our testing ability, not all mutations are detectable. Genetic test results indicate a probability, not a certainty, of developing cancer. Informed consent is critical. She also addressed the shortage of genetic counselors, noting efforts on the part of her organization to increase the workforce, and efforts to maximize the efficiency of the current workforce. She stated that both breast surgeons and genetic counselors bring expertise and vision to the table – we need to develop mechanisms to collaborate so that we may improve the care for our patients.
On a separate note, based on conversations with Ms. Larsen Haidle and the ASBrS leadership, our organizations will be collaborating on a series of educations programs targeted to breast surgeons and genetic counselors. ~DJA
Dr. Judy Boughey (@DrJudyBoughey) discussed “Contemporary Challenges of Clinical Trials” specifically related to surgery. Clinical trials are designed to answer several questions:
– Does a treatment work?
– Does it work better than other treatments?
– Are there side effects?
She noted that treatments in general surgery are half as likely to be recommended based on randomized controlled trial evidence as treatments in internal medicine. Unlike modern drugs, modern operations were introduced well before clinical trials became established, and once a treatment is accepted as standard, testing against placebo becomes difficult.Surgical oncology research represents only 9% of all cancer research. Challenges include lack of funding, surgeon willingness to try new techniques, and technical issues in the performance of new and challenging procedures. We know that patients with cancer who are participating in clinical trials have improved outcomes, yet <5% of adult patients with cancer participate in any clinical trial. 90% of children with cancer below age 5 receive treatment as part of a clinical trial. She concluded by stating that clinical trials are critical to the mission to advance the care of patients and we need to address the challenges of trial development and accrual. ~DJA
Adjuvant Therapies and Outcomes:
@DianeRadfordMD and I co-tweet-moderated on “Adjuvant Therapies and Outcomes”. 2 highlights: Dr. Minetta Liu’s (@BreastCancerMD1) portion on blood tests “liquid biopsies” for breast cancer / recurrence and Dr. Beth DuPree’s (@drbethdupree) portion titled “Integrative Oncology for the Prevention and Treatment of Breast Cancer.” While at present there is no ‘liquid biopsy’ that I’d use in clinical practice, the research presented was encouraging that perhaps in my lifetime breast cancer screening may be reduced to a blood test. Dr. DuPree reminded us that there are several things we can do to address the most common unmet need among breast cancer survivors – the fear of recurrence. She gave the hard truth about alcohol intake (even moderate consumption can increase the risk of breast cancer – she recommends AT LEAST two alcohol free days per week. I recommend patients drink as little as possible), and weight management in minimizing risk. I can’t say it better, so I’ll quote her directly “A disease (breast cancer) created (in part) by lifestyle cannot be cured without lifestyle changes.” ~MSC
Atypical Hyperplasia / Ambiguous Lesions:
Two lectures stood out for me: Dr. Degnim’s talk on atypical ductal hyperplasia and Dr. Calvillo’s talk on the ambiguous needle biopsy. Both of these talks are just as important to me as those on treating an actual cancer.
From Dr. Amy Degnim I am now able to discuss with a patient a risk of developing breast cancer after a biopsy of atypical ductal hyperplasia with a definitive risk of 1% per year. This may vary as we develop biomarkers that will better quantitate risk. Also the number of foci of atypia can be another component of risk assessment and counseling. My hope is that as biomarkers improve we will not have to take every woman with atypical hyperplasia found on needle biopsy to surgery. Also it would be helpful someday to really be more scientific about who we recommend tamoxifen (to reduce risk) for, and how we follow with imaging.
From Dr. Katherina Zabicki Calvillo there was an excellent presentation on lesions that are benign on biopsy, but we consider higher risk, and therefore remove surgically. This includes intraductal papilloma, radial scar lesions, flat epithelial atypia, and lobular neoplasia. Following her guidelines may save many women from unnecessary surgical excisions. This is a very important issue given the recent statements by some that say mammography can lead to harm to the patient by finding lesions that do not truly require treatment. Hopefully as we become more targeted in what we believe is a truly harmful lesion we can justify surgery in these cases, but save other women from over treatment. ~JPC
Contralateral Prophylactic Mastectomy:
Dr. Steven Katz (@skatzskatz)spoke on navigating decisions with patients. He noted that virtually all treatments for breast cancer that confer lifetime benefits are initiated and largely completed within the first year of diagnosis, and that most decisions are made within the first few weeks of diagnosis. Patients receive therapies directed by multiple specialists. 2/3 of women report that their surgical treatment decisions were made by the end of the first encounter – an encounter which often is intense and complex. He described the paradox of choice – decisions require more effort, and the more options presented, the less good we feel about the option we choose. He also noted that autonomy is valued but easily relinquished when decisions are difficult. He reviewed studies he is involved in at the University of Michigan, noting that challenges remain in developing tools that focus patient information and best inform patients of treatment tradeoffs; his results also underscore the responsibility of physicians to navigate the treatment decision process to maximize health outcomes. ~DJA
As a personal comment on the contralateral prophylactic mastectomy (CPM) series that ended the meeting I must say that after 21 years in practice I am still amazed at the rising rate of CPM and the choice to have mastectomy in patients with early stage cancer. After spending so much time and energy over the years to improve lumpectomy techniques and long-term outcomes it is hard for me to understand this trend. The presentations by Dr. Peter Angelos (Ethics of CPM) and Dr. Andrea Pusic (Patient Satisfaction after Prophylactic Mastectomy and Reconstruction: The BREAST Q) were fascinating, and help explain some of the societal factors behind this trend. ~JPC
I would add an observation that is probably not news to the #BCSM community, but clearly is rising to the surface: the value of Twitter for any type of social / professional event. This is the seventh ASBrS meeting I have been to since 2005, and the integration of the ‘online’ discussion has grown exponentially. I find the use of Twitter social media an ideal way to ‘chat’ about the speaker without disrupting the delivery of the sessions. Being able to quietly discuss/banter with those I know (and those I don’t) both during and after the presentations has made the meeting experience much more enjoyable during my career. Just as it’s hard for many of us to imagine life without telephones, I suspect that before long, it will be hard to imagine meetings without Twitter. ~MSC
The Orlando meeting had the highest attendance in the 16 year history of the ASBrS Annual Meeting. This is a testament not only to the organization for putting on such a robust program year after year, but to the 1400 surgeons (almost half of the membership) who took time away from their practices to learn about the latest techniques. I’m very proud to have been elected as President of this incredible organization – one of my many challenges is to put on an equally impressive Annual Meeting in April 2016 in Dallas! ~DJA