Difficult problems in breast cancer diagnosis and treatment

1. An update for Illinois Nurses Elizabeth A. Peralta, MD The Breast Center at SIU Springfield, IL May 2011 Difficult problems in breast cancer diagnosis and treatment

2. 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?

3. 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

4. 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!

5. 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

6. 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

7. 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

8. 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

9. Comparison of Mortality Reduction-Annual versus Biennial Mammogram

10. 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?

11. Z011

12. 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 Giuliano A et al. Ann Surgery 2010 252:426

13. Z011 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

14. Z011 No statistically significant difference

15. 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

16. Identification and treatment of lymphedema after breast cancer treatment • When does lymphedema occur and can it be cured?

17. 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

18. Early Detection of Lymphedema

19. Complete Decongestive Therapy • Manual lymphatic drainage • Compression • Exercise

22. Results achieved by Complete Decongestive Therapy

23. Results achieved by Circumferential Liposuction and Wrapping

24. Lymphedema Algorithm