There were numerous records set at this year’s meeting – most abstracts submitted, most poster presentations, most scientific papers and highest number of breast surgeons – over 1200!!
Many presentations attrached attention but here are a few of my favorite ones.
1) Thermography, basically a heat mapping of each breast, has been performed for >40 years and holds out the possibility of detecting breast cancer without the need for radiation (like mammography – requires radiation but has a low cost) and at a low expense (unlike breast MRI – no radiaiton but very high cost).
“Today, large numbers of patients are requesting breast imaging exams that do not involve radiation and inquiring about thermography in particular,” comments researcher Cara Marie Guilfoyle, MD, Breast Fellow, Bryn Mawr Hospital. “This research sought to evaluate the effectiveness of this relatively new technology.”
Lead researcher Andrea Barrio, MD, FACS, Breast Surgeon, Bryn Mawr Hospital explains that infrared thermography measures heat generated by tissue, which reflects blood flow patterns in the area being evaluated. Through a process known as angiogenesis, rapidly growing cancer lesions typically have an increased blood supply, resulting in higher temperature. Thermal data acquired during a scan undergoes computer analysis for temperature abnormalities, and the device presents doctors with the results.
The study examined 178 patients with abnormal results on mammography, ultrasound or MRI imaging, signaling a possible cancer, who were undergoing minimally invasive breast biopsy for further evaluation. Both the patient’s affected breast and the contralateral non-affected breast were scanned using the No Touch Breast Scan (NTBS) infrared thermography system prior to minimally invasive biopsy. The thermal scans were then interpreted by a computer that could be set on high specificity (only pick out things that will be cancer and miss some subtle cancers) or high sensitivity (pick out all cancers but also a bunch of other things). All results were compared with pathology findings, following biopsy and then followed over time with physical exam and mammography.
Thermography could pick out the cancers but also identified >50% of the negative biospies as positive (sensitivity 87%, specificity 48%, postiive predictive value 40%). On the contralateral side (the side not getting a biopsy), thermography was positive between 24% of the time (high specificity setting) and 47% (high sensitivity setting). None of the contralateral breasts have developed any signs of cancer.
In conclusion, Dr. Barrio states
“Therefore, our research shows infrared thermography cannot be used as a successful adjunct to mammography nor can it replace any of the screening modalities in standard practice today. Mammography remains the gold standard.”
Bottomline – I wished thermography worked (like so many other ‘treatments’ in cancer patients) but it does not and we should not be using
2) Male breast cancer – In an interesting epidemiological study, Dr. John Greif analyzed the National Cancer Data Base (NCDB) and discovered that the five-year survival rate for women overall was 83%, compared to 74% for men. When analyzed by disease stage, the differences were greatest for the early stages of breast cancer. They were highly significant during stage 0 (94% vs. 90%), stage 1 (90% vs. 87%) and stage 2 (82% vs. 74%), while survival at stage 3 and 4 were similar.
Bottom line, men can get breast cancer too (~1% of all breast cancer patients) but often present wtih larger tumors that are more likely to have spread ot the axillary lymph nodes. Later presentation adversely affects survival – so don’t ignore a breast mass even if you are a man.
3) Can women with locally advanced breast cancers who have a good response to neoadjuvant chemotherapy be safely treated with lumpectomy? Short answer (and long answer) absolutely!! Women with big tumors who go straight to surgery almost always end up with a mastectomy and they still have to get radiation! So why not try to shrink the tumor first with chemotherpay and if they respond well, only do a lumpectomy (especially since either way they are going to get radiation). Well, Dr. Elizabeth Cureton, Breast Surgical Oncology Fellow at UC San Francisco showed that it was in fact safe to save the breast if the patient responded to chemotherapy. This study was part of the revolutionary trial called I-SPY 1 and examined 206 patients classified as high risk. All patients had chemotherapy before surgery. Ninety study participants were treated with lumpectomy and 116 with mastectomy. Choice of surgical treatment and the use of post-operative radiation therapy were at the discretion of the treating physician. Patients were followed for an average of 3.9 years after diagnosis.
“Overall these high-risk patients had a low risk of local recurrence, but a significantly higher risk of tumor metastasis in other areas of the body,” comments Dr. Laura Esserman, Professor in the Departments of Surgery and Radiology and Affiliate Faculty of the Institute for Health Policy Studies, University of California, San Francisco Medical Center; Director of the Carol Franc Buck Breast Care Center; and Co-Leader of the Breast Oncology Program at the UCSF Helen Diller Family Comprehensive Cancer Center. “With today’s advanced treatments–which could include hormone therapy, chemotherapy and radiation depending on the patient–we found that distant metastatic cancers, not local recurrences, are the major risk for this patient population. Yet, many treatment plans provide aggressive therapies, such as mastectomy and radiation therapy, to prevent local recurrence in this patient group.”
Bottomline, women who respond well to pre-surgical chemotherapy may not require other aggressive local treatment and may do well with a lumpectomy instead of mastectomy.
4) Brachytherapy controls the tumor bed as well (?better) than whole breast irradiaiton – A personal favorite (disclosure – this is my study).
In the ASBrS study, 50 patients treated with brachytherapy (3.5%) developed an ipsilateral breast tumor recurrence (IBTR), 14 (1.1%) at the initial tumor site and 36 (2.6%) elsewhere in the breast. For invasive cancers, IBTR was associated with estrogen receptor (ER) negative disease. For DCIS, IBTR was associated with age <50 or close/positive surgical margins.
“Prior studies have demonstrated that the risk of cancer recurrence in the conserved breast is similar for WBI or APBI. Following WBI, most breast recurrences are at the initial tumor site, and relatively few are elsewhere in the breast,” says Dr. Peter Beitsch, Director of the Dallas Breast Center, Co-Principal Investigator for the ASBrS MammoSite Registry and lead author on the ASBrS study. “This study demonstrated that for patients treated with APBI, this ratio was reversed: most breast recurrences were elsewhere in the breast and only a minority were at the initial tumor site. These data suggest that although tumor control in the breast appears to be similar for APBI and WBI, disease control at the initial tumor site may be better with APBI.”
The findings of the ASBrS study contrast with the MD Anderson Cancer Center JAMA study, which also compared APBI to WBI. That study compared the results of breast brachytherapy to WBI in 92,735 women 67 or older, 7% treated with brachytherapy and 93% with WBI. At 5 years of follow-up, compared to WBI, survival was the same (87.6% vs. 87%) but the brachytherapy patients had higher rates of subsequent mastectomy (4% vs. 2%), infectious complications (16% vs. 10%), non-infectious complications (16% vs. 9%), pain (15% vs. 12%), fat necrosis (8% vs. 4%) and rib fracture (4.5% vs. 3.6%).
Dr. Beitsch notes that the limitations of the MD Anderson study are that 1) it is based on Medicare claims data, which often does not provide an accurate clinical picture, 2) many endpoints are “soft”, poorly defined and difficult to quantify, 3) reported complication rates after breast surgery and radiotherapy vary widely, and depending on study design are subject to under- or over-reporting, and 4) the authors’ inferences of harm to patients from breast brachytherapy are at best speculative.
An extensive body of literature, drawing on the ASBrS Registry and other sources, suggests that for APBI 1) local control is comparable to WBI, 2) local control is similar for women younger vs. older than age 70, 3) infectious complications are similar, 4) non-infectious complications including fat necrosis are similar, 5) pain is comparable, 6) cosmesis is excellent, and 7) survival, including overall, disease-free, and disease-specific survival, is similar to WBI.
Standard treatment for early stage breast cancer often involves breast conserving surgery (lumpectomy) and WBI. Clinical trial data clearly demonstrate the need for some form of radiation therapy following lumpectomy to reduce the rate of tumor recurrence. APBI may offer advantages such as reduced treatment time, reduced radiation dose to normal tissue such as lungs, ribs and heart, increased utilization of postoperative radiation therapy leading to lower recurrence rates, and an increased rate of lumpectomy compared to mastectomy in areas with limited patient access to WBI centers.
Dr. Beitsch also notes: “We radiate the breast to control undetectable cancer cells left behind around the lumpectomy cavity. Common sense would say internally targeted radiation would be the best method to kill these cells. We now have strong data to support that, and that the complication rate is very low from this form of therapy.”
“APBI appears to be safe and effective treatment for properly selected breast conservation patients,” says Dr. Hiram S. Cody III, Attending Surgeon, Breast Service Department of Surgery, Memorial Sloan-Kettering Cancer Center and Professor of Clinical Surgery, Weil Cornell Medical College. Dr. Cody, who is also a member of the Executive Committee and Board of Directors for ASBrS, notes that the ASBrS continues to support its Consensus Statement on APBI and guidelines for patient selection (August 15, 2011 revision): (http://www.breastsurgeons.org/statements/PDF_Statements/APBI.pdf).
However, Dr. Cody also states, “We wish to emphasize that although the six year results of APBI are encouraging, they do not conclusively establish equivalence with WBI, for which the supporting data include multiple randomized trials with follow-up exceeding 20 years, and meta-analyses that conclusively link local control and survival. APBI must ultimately be held to the same standard, and a randomized trial, NSABP B-39, directly compares partial breast irradiation (by interstitial catheters, balloon devices, strut-based devices, or external beam) with WBI and promises to better define the ultimate role of APBI.”