Deanna Attai

Adjuvant Radiotherapy for Older Women after Breast Conserving Surgery – 4 randomized clinical trials addressed if elderly patients with low-risk breast cancer need radiation therapy after breast conserving therapy: NSABP B-21, A. Fyles, CALGB 9343, and PRIME II studies o Meta-analysis of these 4 studies: 2387 patients across all trials, early stage breast cancer, hormone receptor positive. Accelerated partial breast irradiation may be an option, but some studies have shown higher local recurrence and poorer cosmetic result (depending on treatment method) – While toxicities of radiation therapy have improved with more modern techniques, logistical concerns such as time, need to travel, and cost may be of higher concern for older women Dr. Laura Dominici – Dana Farber Cancer Institute Reconstruction and Body Image in Young Patients Important for patients to understand the oncologic outcomes of their decisions, and for physicians to promote shared decision making that takes into account patient preferences and concerns Dr. Jo Chien – University of California, San Francisco Fertility in Young Breast Cancer Patients – 51% of women under age 40 with breast cancer are concerned about fertility; 38% desire to have future children but up to 97% are at risk of treatment related infertility. Fertility preservation associated with less regret among young cancer survivors – Less than 25% of general oncologists refer young breast cancer patients to fertility specialists – Factors impacting risk of chemotherapy-induced ovarian failure: older age, baseline ovarian reserve, type of chemotherapy, and chemotherapy dose / duration

Approximately 6000 screening mammography + same-day screening ultrasounds (SM + US) in 3386 women were matched to 30,000 screening mammograms (SM) without same-day screening ultrasounds in 15,000 women. The breast cancer detection rate in both groups (SM + US and SM alone) was essentially identical – 5.4 vs 5.5 breast cancers detected per 1000 screening exams. SM + US resulted in higher false positive biopsy rates (52 versus 22 per 1000 screens) and more often a recommendation for additional, short-term follow up for “probably benign” findings (3.9% vs 1.1%) compared with SM alone. The authors noted some limitations of their study include lack of information on the experience and expertise of the ultrasonographers, lack of information on whether or not patients underwent hand-held or automated breast ultrasound, and the possibility of misclassification of some studies, which they estimated at 4.3%.

The “lay person letter” that patients receive with information about their mammogram results, and aspects of mammography facility quality measures, are part of the MQSA. Approximately 40% of patients undergoing mammograms have dense breasts, a subjective measure of the proportion of glandular tissue (which tends to appear white, or “dense” on mammogram) versus fatty tissue (which appears darker) on mammogram. Diagnosed with advanced breast cancer after years of normal mammograms, she was informed that her prior mammograms could not identify the cancer due to “dense breasts”. Tomosynthesis, or 3D mammography, is a form of mammography that can improve the rate of breast cancer detection and can also reduce the rate of “false alarms” or callback examinations.

The researchers found that when there is a pCR (including invasive and in-situ disease) after neoadjuvant chemotherapy, the likelihood of having any cancer in the axillary lymph nodes is extremely low if the patient had normal axillary lymph nodes demonstrated on ultrasound prior to beginning therapy. A much larger study using the US National Cancer Database noted similar findings, but in addition, highlighted the need to perform axillary surgery in cases where there was initial biopsy-proven cancer in the lymph nodes prior to chemotherapy. Again, surgeons asked questions, and the NSABP B-06 trial was performed – this study found no difference in overall survival whether patients underwent a mastectomy with lymph node removal, a lumpectomy with lymph node removal, or a lumpectomy with lymph node removal and radiation therapy. Sentinel node biopsy and targeted node dissection, removing a smaller number of carefully identified lymph nodes (even in some settings where the cancer has spread into the lymph nodes) results in lower rates of lymphedema, chronic pain and arm mobility problems without impact on survival or recurrence.