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Approach Considerations
Surgery is considered primary treatment for breast cancer, as many patients with early-stage disease are cured with surgery alone. The goals of breast cancer surgery include complete resection of the primary tumor with negative margins to reduce the risk of local recurrences, and pathologic staging of the tumor and axillary lymph nodes for providing necessary prognostic information. Several different types of operations are available for the treatment of breast cancer. Adjuvant treatment for breast cancer involves radiation therapy and a variety of chemotherapeutic and biologic agents.
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Partial-breast irradiation is employed in early stage breast cancer following breast-conserving surgery as a way of delivering larger fraction sizes while maintaining a low risk of late effects. Several techniques that can deliver this therapy include interstitial brachytherapy (multiple catheters placed through the breast) and intracavitary brachytherapy (a balloon catheter inserted into the lumpectomy site [ie, MammoSite]). Treatment is typically for 5 days, twice daily. These techniques have shown low local recurrence rates comparable to EBRT in several nonrandomized studies. The American Society of Breast Surgeons (ASBrS) recommends the following selection criteria when considering patients for treatment with accelerated partial breast irradiation: Age 45 years and older Invasive ductal carcinoma or DCIS Total tumor size (invasive and DCIS) 3 cm or smaller Negative microscopic surgical margins of excision Axillary lymph node/sentinel lymph node negative Potential complications of partial-breast irradiation are catheter placement, followed by removal secondary to inadequate skin spacing, infection, seroma, fibrosis, chronic pain, or disease recurrence.
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partial breast radiation given over 5 days to standard whole-breast radiotherapy are currently under way. Tamoxifen is the only hormonal therapy currently approved for adjuvant therapy in patients treated with breastconserving surgery and radiation for DCIS. Currently, a clinical trial evaluating the role of the aromatase inhibitor anastrozole as adjuvant therapy in DCIS has met its accrual and results are anticipated.
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This disease is more likely to stain negatively by IHC for ER and PR, somewhat more likely to be positive for HER2 overexpression, and both angiogenesis and lymphangiogenesis appear to be increased by microvessel density or RNA-based gene expression arrays. Within IBC, however, may be found the same molecular subtypes of breast cancer as originally described for non-inflammatory breast cancer.
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never operate in the setting of metastatic disease has certainly been dispelled in favor of critical evaluation of whether surgically achieved local control can lead to improved survival as a part of multimodal treatment.
Long-term Monitoring
Follow-up guidelines
There is no consensus among oncologists as to the appropriate and optimal follow-up for long-term breast cancer survivors. The majority of relapses, both local and distant, occur within the first 3 years, especially in higher risk and ER-negative patients. The 2007 ASCO guidelines do not support the use of tumor biomarkers, including CEA, CA15.3, and CA27.29, for monitoring patients for recurrence after primary breast cancer therapy. Table 6, below, lists the NCCNs recommendations for breast cancer patients in the adjuvant setting. Table 6. Follow-up Recommendations for Breast Cancer Survivors per NCCN Guidelines (Open Table in a new window) Intervention* Mammography Year 1 Year 2 Year 3-5 Year 6+ q4 mo q6 mo Annually
post-BCS irradiation)
NR Annually q1-2 y
NR
NR
NR
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Bone scan, blood counts, LFTs, and tumor markers are not routinely recommended
Postsurgical imaging
Women who have had surgery for breast cancer may still require breast cancer screening with mammography. If a woman had a total mastectomy, then the other breast requires yearly follow-up, because she is still at higher risk of developing cancer in the remaining breast. If she had subcutaneous mastectomy, partial mastectomy, or lumpectomy, then that breast itself requires follow-up mammography. The first mammogram is best performed 6 months postoperatively to provide a baseline for the new postoperative and radiation changes. Thereafter, mammography may be performed every 6-12 months for screening and followup. Go to Postsurgical Breast Imaging for more information on this topic. Monitoring of metastatic disease Recommendations for monitoring disease response in the metastatic setting vary. In general, monthly evaluations consisting of a history and physical examination to evaluate progression of disease and toxicities are reasonable. Tumor markers, such as CEA, CA15.3, and CA27.29, can be used in conjunction with diagnostic imaging, history, and physical examination for monitoring while on active therapy. CA15.3 and CA27.29 levels correlate with the course of disease in 60-70% of patients, whereas CEA levels correlate in 40% of patients. However, data are insufficient to recommend the use of CEA, CA15.3, or CA27.29 alone for monitoring response to treatment. Caution should be used when interpreting rising CEA, CA15.3, or CA27.29 levels during the first 4-6 weeks of a new therapy, as spurious early rises may occur. Standardized guidelines for imaging are not yet established and should be tailored to each patient. In general, CT scanning (chest, abdomen, and pelvis), MRI, bone scanning, or PET/CT scanning are performed when symptoms change or tumor markers rise. Circulating tumor cells are cells present in the blood that possess antigenic or genetic characteristics similar to a primary tumor type. The FDA has recently approved the CellSearch System (Veridex, Raritan, NJ) for the detection of circulating tumor cells in patients with metastatic breast cancer. This system captures circulating tumor cells using an immunomagnetic process with an epithelial cell adhesion molecule coated with magnetic beads and cytokeratin antibodies. A circulating tumor cell is identified when it is cytokeratin- and DAPI-positive but CD45-negative. Studies done by Cristofanilli using the CellSearch System have shown a prognostic utility and predictive use for circulating tumor cells in metastatic breast cancer patients.[15] Circulating tumor cellpositive patients (>5 CTCs/7.5 mL blood) were shown to have a worse progression-free survival (17%) and overall survival than the circulating tumor cellnegative patients (36%). The presence of more than 5 circulating tumor cells before hormonal or chemotherapy treatment and following the first cycle of treatment also predict a worse outcome. However, studies to date have used small sample sizes, and no data have shown that use of circulating tumor cell testing affects overall survival or improves on quality of life. Per ASCO guidelines, the use of circulating tumor cell testing in breast cancer is not recommended for the diagnosis of breast cancer, nor should test results influence treatment decisions. The Southwest Oncology Group (SWOG) is conducting a large, prospective trial to address the clinical use of circulating tumor cells in breast cancer. emedicine.medscape.com/article/1947145-treatment 6/10
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cancer.
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Society of Surgical Oncology Disclosure: Genomic Health Grant/research funds Speaking and teaching; Agendia Grant/research funds Speaking and teaching; Surgical Tools Grant/research funds Research; Sysmex Grant/research funds Research Robert B Livingston, MD Professor of Clinical Medicine and Director, Clinical Research Shared Services, Arizona Cancer Center Robert B Livingston, MD is a member of the following medical societies: American Association for Cancer Research, American Federation for Clinical Research, and American Society of Clinical Oncology Disclosure: Nothing to disclose. Hanan Makhoul, MD Staff Physician, Department of Internal Medicine, University of Arkansas School of Medicine Disclosure: Nothing to disclose. Issam Makhoul, MD Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology Disclosure: Nothing to disclose. Robert C Shepard, MD, FACP Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American College of Physician Executives, American College of Physicians, American Federation for Clinical Research, American Federation for Medical Research, American Medical Association, American Medical Informatics Association, American Society of Hematology, Association of Clinical Research Professionals, Eastern Cooperative Oncology Group, European Society for Medical Oncology, Massachusetts Medical Society, and Society for Biological Therapy Disclosure: Nothing to disclose. Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) Senior Lecturer, Director of Breast Service, Department of Surgery, Imperial College School of Medicine; Consultant Surgeon, Northwick Park and St Marks Hospitals, UK Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada and Royal College of Surgeons of Edinburgh Disclosure: Nothing to disclose. Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose. Wiley Souba, MD Chairman, Professor, Department of General Surgery, Pennsylvania State College of Medicine; Chief Surgeon, The Milton S Hershey Medical Center Disclosure: Nothing to disclose. Rachel Swart, MD, PhD Assistant Professor of Medicine, Department of Hematology and Oncology, Arizona Cancer Center, University of Arizona
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Rachel Swart, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society of Clinical Oncology, Arizona Medical Association, and Southwest Oncology Group Disclosure: Roche Grant/research funds Other Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Simon Thomson, MB, BCh, MD, FRCS Specialist Registrar, Department of Breast and Endocrine Surgery, Northwick Park Hospital, UK Simon Thomson, MB, BCh, MD, FRCS is a member of the following medical societies: British Medical Association Disclosure: Nothing to disclose.
References
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13. Bear HD, Anderson S, Smith RE, et al. Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer:National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. May 1 2006;24(13):2019-27. [Medline]. 14. [Best Evidence] [Guideline] Visvanathan K, Chlebowski RT, Hurley P, Col NF, Ropka M, Collyar D, et al. American Society of Clinical Oncology clinical practice guideline update on the use of pharmacologic interventions including tamoxifen, raloxifene, and aromatase inhibition for breast cancer risk reduction. J Clin Oncol. Jul 1 2009;27(19):3235-58. 15. Cristofanilli M. Circulating tumor cells, disease progression, and survival in metastatic breast cancer. Semin Oncol. Jun 2006;33(3 Suppl 9):S9-14. 16. Xeloda [package insert]. South San Francisco, Calif: Genentech; November 2009. 17. Ellence [package insert]. New York, NY: Pfizer; February 2007. 18. Baselga J, Corts J, Kim SB, Im SA, Hegg R, Im YH, et al. Pertuzumab plus trastuzumab plus docetaxel for metastatic breast cancer. N Engl J Med. Jan 12 2012;366(2):109-19. [Medline]. 19. The U.S. Food and Drug Administration. FDA begins process to remove breast cancer indication from Avastin label. FDA NEWS RELEASE: Dec. 16, 2010. Available at http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm237172.htm. Accessed July 15, 2011. 20. The U.S. Food and Drug Administration. Postmarket Drug Safety Information: Avastin (bevacizumab) Information, Update, 6/29/2011. Accessed July 15, 2011. [Full Text]. 21. Herceptin [package insert]. South San Francisco, Calif: Genentech; October 2010. 22. Tykerb [package insert]. Research Triangle Park, NC: GlaxoSmithKline; January 2010. 23. Femara [package insert]. East Hanover, NJ: Novartis; April 2010. 24. Fareston [package insert]. Memphis, Tenn: GTX; December 2004. Medscape Reference 2011 WebMD, LLC 25. James TA, Mace JL, Virnig BA, et al. Preoperative needle biopsy improves the quality of breast cancer surgery. J Am Coll Surg. Oct 2012;215(4):562-8. [Medline]. 26. Mulcahy N. Breast cancer needle biopsy in 'granular' detail. Medscape Medical News. Available at http://www.medscape.com/viewarticle/772152. Accessed Oct 15 2012.
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