Searching PubMed for breast cancer–related papers in 2020, Helen Pass, MD, the chief of breast surgery and co-director of the Stamford Hospital Breast Cancer Center, in Connecticut, found 14,000 in English alone. Dr. Pass presented the ones she considered most compelling at the 2021 virtual meeting of the American College of Breast Surgeons.
“I tend to select those that are landmark studies, have clinical value, or were a source of patient inquiries or national media attention,” Dr. Pass said.
The Tyrer-Cuzick Model Inaccurately Predicts Invasive Breast Cancer Risk in Women With LCIS
(Valero MG, et al. Ann Surg Oncol 2020;27[3]:736-740)
The Tyrer-Cuzick (TC) model has been found to overestimate the risk for breast cancer in women with atypical ductal hyperplasia. To assess the accuracy of the TC model in women with lobular carcinoma in situ (LCIS), researchers conducted a retrospective review of 1,192 women, of whom 128 developed invasive breast cancer. Their 10-year cumulative incidence was 14%, but the median 10-year TC score was 20%. The authors concluded that the model may overestimate the risk for invasive cancer in women with LCIS and should not be used in this high-risk group.
“An editorial accompanying this paper concluded that the population estimate of 1.5%-per-year breast cancer risk after the diagnosis of LCIS is probably the most accurate data to use. This means that at five years, everyone with LCIS would have a lifetime risk of 7.5%, making them eligible for chemoprevention; and at 20 years, the risk would be 30%, above the screening threshold for MRI. No matter what model we use, LCIS is recognized as a high-risk condition, and these options should be offered to patients,” Dr. Pass said.
Breast Cancer Screening Recommendations: African American Women Are at a Disadvantage
(Rebner M, Pai V. J Breast Imaging 2020;2[5]:416-421)
The authors of this paper make the case that guidelines for breast cancer screening are disadvantageous to African American women based on the fact that breast cancer is more common before age 50 in Black women than non-Black women, that triple-negative cancer is more common in Black women, that BRCA mutations are more common in Black women than in white women except for those of Ashkenazi Jewish ancestry, and that breast cancer mortality has decreased to a lesser degree in Black women since 1990.
“Although the reasons for the above are multifactorial, one simple step may be to modify screening recommendations based on risk—which the U.S. Preventive Services Task Force states we should do—but, more importantly, to incorporate race into the risk calculators,” Dr. Pass said.
Survival Outcomes of Screening with Breast MRI in Women at Elevated Risk of Breast Cancer
(Bae MS. J Breast Imaging 2020;2[1]:29-35)
To compare combined MRI plus mammography with mammography alone, researchers evaluated cancer detection rates and overall survival in 3,002 women with an increased lifetime risk for breast cancer. The cancer detection rate was higher in the MRI plus mammogram group (1.4% vs. 0.5%), as was overall survival. The authors concluded that combined MRI and mammography in women with elevated risk improves both end points.
“These results differ from the previous study that showed no difference, probably because the two groups compared were contemporaneous instead of sequential. For high-risk populations, the addition of MRI to mammogram is beneficial; however, the role of MRI in screening women with a personal history of breast cancer remains controversial,” Dr. Pass said.
Fertility Preservation Before Breast Cancer Treatment Appears Unlikely to Affect Disease-free Survival at a Median Follow-up of 43 Months After Fertility-Preservation Consultation
(Letourneau JM. Cancer 2020;126[3]:487-495)
Another in a series of articles showing that fertility preservation is unlikely to affect disease-free survival, this retrospective review of 329 patients, 207 of whom had fertility preservation and 122 who did not, found no difference in overall disease-free survival over a median follow-up of 43 months. This study included women with estrogen receptor–positive cancer who underwent neoadjuvant chemotherapy with their tumor in situ during their fertility preservation treatment.
“The strengths of this study compared to others are that it was large, it used modern fertility preservation techniques and had a longer follow-up. It was also more aligned with real-world use, with the inclusion of neoadjuvant chemotherapy (NAC) patients, those who were younger and those with more aggressive disease. So, again, I think we can reassure our patients that fertility preservation is safe and should be offered to women desiring future fertility,” Dr. Pass said.
Perioperative use of gabapentinoids for the management of post-operative acute pain: a systematic review and meta-analysis
(Verret M, et al. Anesthesiology 2020;133[2]:265-279. See also the accompanying editorial, “Perioperative gabapentinoids: deflating the bubble.”)
In this review of gabapentinoids as a pain treatment after surgery (comprised of 281 randomized controlled trials and 24,682 adult subjects), researchers found gabapentinoids to be associated with significantly lower pain intensity compared with control treatment. But this difference—less than 10 points on a scale of 0 to 100 at six, 12 and 48 hours—was not clinically meaningful. Gabapentinoid use was also associated with a significantly lower level of opioid use, but again, this was not clinically meaningful, and there was no effect on long-term opioid use.
Gabapentinoids were associated with a host of negative effects, such as dizziness, balance disorders, visual disturbance, sedation and cognitive impairment, and postoperative pulmonary complications up to and including mechanical ventilation, and hence increased length of stay. The authors concluded that the available literature does not support the routine use of gabapentinoids for postoperative pain prevention or treatment.
“The French Society of Anesthesia and Intensive Care Medicine now states that gabapentinoids should not be used systemically or in outpatient surgery as part of ERAS protocols, and it calls into question our ERAS protocols. Personally, I think a greater emphasis on preoperative teaching and expectation setting is needed, as many patients expect no pain after surgery.
“I also recommend reading the accompanying editorial by the editor-in-chief of Anesthesiology, as it makes many important, salient points,” Dr. Pass said.
Accuracy of post-neoadjuvant chemotherapy image-guided breast biopsy to predict residual cancer
(Tasoulis MK, et al. JAMA Surg 2020;155[12]:e204103)
In this assessment of image-guided breast biopsy to predict residual cancer in the breast after NAC, researchers reported a false-negative rate of 18% in 159 of the 166 post-NAC breast cancer patients for whom the core biopsy was representative. But when selection was limited to patients who did not have lobular cancer, whose residual imaging abnormality was 2 cm or less, and those who’d had at least six vacuum-assisted core specimens taken, the false-negative rate fell to 3.2%. The authors concluded that a standard protocol using at least six representative samples in patients with less than or equal to 2 cm of residual imaging abnormality can help reliably identify patients after NAC with no residual disease.
“I think many of us are skeptical that we can accurately select a cohort of patients after NAC in whom the ultimate surgical deescalation could occur, and I have to applaud Henry Kuerer for championing this trial,” Dr. Pass said.
Impact of Surgical Margins in Breast Cancer After Preoperative Systemic Chemotherapy on Local Recurrence and Survival
(Wimmer K, et al. Ann Surg Oncol 2020;27[5]:1700-1707)
In this retrospective review of 406 women with a median follow-up of 84.3 months, researchers found no difference between narrow and wide margins in relation to local recurrence–free survival or disease-free survival, and patients with a pathologic complete response had the best local recurrence–free and disease-free survival.
“What this tells us is that the ‘no ink on tumor’ definition of a negative margin remains appropriate even after NAC, that removing normal tissue is not beneficial,” Dr. Pass said.
Surgical Margins and Adjuvant Therapies in Malignant Phyllodes Tumors of the Breast: A Multicenter Retrospective Study
(Neron M, et al. Ann Surg Oncol 2020;27[6]:1818-1827)
In this multicenter review of 212 patients with malignant phyllodes tumors, wide margins (=8 mm) were not superior to narrow margins (3-7 mm), and mastectomy improved local recurrence–free survival but not overall survival. The authors concluded that surgery remains the cornerstone of treatment; that a margin of 3 mm or greater seems optimal; that when needed, a second surgery should be performed to obtain these margins; and that breast conservation is a viable option for appropriate tumors.
“Historically, a 1-cm margin has been advocated for malignant phyllodes tumors. This large study with accurate information on margin width supports the use of at least a 3-mm margin. It also supports the use of breast-conserving therapy in appropriately selected patients, and it made the note that although preoperative diagnosis of malignant phyllodes tumors is difficult, it does facilitate proper surgical planning,” Dr. Pass said.
Microscopic Extracapsular Extension in Sentinel Lymph Nodes Does Not Mandate Axillary Dissection in Z0011-Eligible Patients
(Barrio AV. Ann Surg Oncol 2020;27[5]:1617-1624)
To determine the necessity of axillary dissection in patients with microscopic extracellular extension (mECE), researchers compared outcomes in 811 patients with or without mECE treated with sentinel lymph node biopsy alone.
All patients were clinically T1 or T2, node-negative, and prospectively managed according to Z0011 criteria; mECE was identified in 31% of the 685 patients with positive nodes who did not undergo complete axillary dissection. At a median follow-up of 41 months, mECE did not affect the five-year rate of nodal recurrence, local recurrence or distant recurrence. The authors concluded that in Z0011 eligible patients, the presence of mECE should not be considered an indication for complete axillary lymph node dissection.
“To me, this data is very reassuring. However, remember that patients with gross ECE have traditionally not been offered SLN [sentinel lymph node] biopsy and this distinction is important,” Dr. Pass said.
Omitting Radiotherapy Is Safe in Breast Cancer Patients 70 Years Old After Breast-Conserving Surgery Without Axillary Lymph Node Operation
(Zhong Y, et al. Sci Rep 2020;10[1]:19481)
Previous studies have shown that omitting radiotherapy after breast-conserving surgery with axillary surgery is safe in elderly patients. But can both lymph node surgery and radiation be avoided in women over 70? This retrospective analysis of 481 older patients, with a median follow-up of five years, found a higher in-breast tumor recurrence in the 302 patients who had neither nodal surgery nor radiation, but no difference in disease-free survival, breast cancer–specific survival or distant metastasis rate compared with patients who underwent more extensive treatment.
“I always felt like I struggled between omitting a sentinel lymph node biopsy or omitting radiation therapy, and I found it very reassuring that we may be able to omit both of these treatments for women with early-stage, hormone receptor–positive, HER2-negative disease who are 70 years of age or older,” Dr. Pass said.
This article is from the September 2021 print issue.
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