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DIFFICULT PROBLEMS IN BREAST CANCER DIAGNOSIS AND TREATMENT
An update for Illinois NursesElizabeth A. Peralta, MDThe Breast Center at SIUSpringfield, IL May 2011
2011 Update on these Continuing Problems: 1. What age and what
interval for screening mammography is best?
2. Is axillary dissection still necessary?
3. When does lymphedema occur and can it be cured?
Competing Recommendations USPSTF: mammography every
1‐2 years for women age 40‐69
ACS: annually starting at age 40
ACOG: mammography every 1‐2 years for women 40‐49 then annually thereafter
ACR: mammography annually starting at 40
USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade B
recommendation)
Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)
Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)
Recommends against teaching breast self‐examination (Grade D recommendation)
Th e main difference is the fine print!
USPTSF New Guidelines:
Biennial screening mammography for women ages 50‐74
Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)
Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)
Recommends against teaching breast self‐examination (Grade D recommendation)
https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm
USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade B
recommendation)
Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms
Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)
Recommends against teaching breast self‐examination (Grade D recommendation)
https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm
USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade B
recommendation)
Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)
Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older
Recommends against teaching breast self‐examination (Grade D recommendation)
https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm
USPTSF New Guidelines: Biennial screening mammography for women ages 50‐74 (Grade
B recommendation)
Decision to start regular, biennial screening mammography before the age of 50 should be an individual one and take patient context into account, including patient values regarding specific benefits and harms (Grade C recommendation)
Current evidence insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I statement)
Recommends against teaching breast self‐examination
https://www.uspreventiveservicestaskforce.org/asptsf/uspsbrca.htm
Comparison of Mortality Reduction-Annual versus Biennial Mammogram
ComparisonStartingAges
AverageScreeningper 1000Women
PercentMortalit
yReducti
on
Cancer DeathsAverted per 1000 Women
Life YearsGainedper 1000Women
False + per 1000Women
Unnecess--aryBiopsies per1000 Women
BIENNIAL
40‐69yo
13,865 16 6.1 120 1250 88
50‐69yo
8,944 15 5.4 99 750 55
ANNUAL
40‐69yo
27,583 22 8.3 164 2250 158
50‐69yo
17,759 20 7.3 132 1350 95
Impact of SLN trials on treatment of positive nodes in breast cancer
When is ALND not necessary, and in what circumstances is it still recommended?
Z011
Most of the patients in this trial had a low axillary tumor burden. Caution at the initiation of the study led to an attempt to assure that women with high tumor burden were not randomized to SLND alone.
Therefore, eligibility requirements specified that when surgeons felt that there was extensive axillary disease upon palpation of the nodal basin during the SLND, they were required to exclude such patients by demonstrating 3 or more involved SNs. If patients had 3 or more positive SNs, they were not eligible for randomization
Z011
Giuliano A et al. Ann Surgery 2010 252:426
The number of patients with 2 or more positive nodes identified in the ALND group was 140 (40.8%) compared with 91 (21.9%) in the SLND
Z011
Z011
SLND (n=436) ALND (n=420)
Local Recurrence 8 (1.8%) 15 (3.6%)
Regional Recurrence 4 (0.9%) 2 (0.4%)
Median Survival Not reached at 6.7yr Not reached at 6.7 yr
No statistically significant difference
So when is Axillary Lymph Node Dissection Unlikely to Provide Benefit? Tumor less than 5 cm and amenable to
lumpectomy, clinically negative nodes Combined with adjuvant radiation and
systemic therapy 1 or 2 positive sentinel nodes with no
extracapsular extension Age over 50 years, and tumor not
showing aggressive features This combination of features is
anticipated to apply to about 20 % of women with breast cancer
Identification and treatment of lymphedema after breast cancer treatment
When does lymphedema occur and can it be cured?
Secondary Lymphedema after Breast Cancer Treatment
Interstitial accumulation of protein-rich fluid, with subsequent inflammation, adipose tissue hypertrophy, and fibrosis
Onset may be months to years after treatment
Risk factors: mastectomy (versus lumpectomy), complete dissection with radiation therapy (versus sentinel node only), obesity
Early Detection of Lymphedema
Complete Decongestive Therapy
Manual lymphatic drainage Compression Exercise
Results achieved by Complete Decongestive Therapy
Results achieved by Circumferential Liposuction and Wrapping
Lymphedema Algorithm