Deanna Attai, MD, FACS
Jennifer Zook, MD
After decades of research, multiple randomized trials have shown breast conservation therapy (BCT) to be equivalent to mastectomy, both in terms of survival and the risk of local recurrence.
Yet despite the advantages of BCT, several recent studies indicate an increase in national mastectomy rates in the past decade. Breast surgeon Deanna Attai, MD, FACS, and radiation oncologist Jennifer Zook, MD, discuss the state of breast conservation therapy, factors behind the rising mastectomy rates, and how shortened forms of radiation therapy like accelerated partial breast irradiation (ABPI) may increase patient acceptance of BCT.
Are there varying definitions of what constitutes breast conservation therapy, in terms of the width of excision or amount of tissue removed? How do you define BCT?
Deanna Attai, MD, FACS: The goal of breast conservation refers to removal of the tumor with a surrounding margin while leaving a cosmetically acceptable result. There is no standard definition of an adequate margin, although we do know that in many situations, more is not necessarily better. It is generally accepted, however, that clear surgical margins are important to help reduce the risk of local recurrence. Depending on the individual patient and the characteristics of her tumor, however, the definition of an adequate margin may range from “no tumor on ink” to 5 mm.
Jennifer Zook, MD: There are a variety of opinions when it comes to the definition of what constitutes an adequate resection in breast conserving surgery. Some physicians advocate for no tumor at the inked margins, as defined by the NSABP B-06 trial, while others advocate for wider surgical margins such as 2 mm or even wider at 5 mm. I usually consider at least 2 mm as my ideal negative margin, but many of the surgeons I work with are okay with less than that (1 mm or even < 1mm).
Do you consider BCT to be underutilized? Does this explain the recent increase in mastectomy rates?
Dr. Zook: I believe BCT is underutilized, and we have been seeing an increase in mastectomy rates over the past 5 years, when we had initially seen a decrease in the early 2000s. This is likely multifactorial in nature. Lack of insurance, rural versus urban locations, access to radiation facilities and length of treatment, young age, more sensitive imaging such as MR, increased media coverage of celebrities and national figures who have breast cancer – along with a variety of other reasons – have likely contributed to this trend.
Dr. Attai: The decision to undergo mastectomy versus lumpectomy when you have a choice can be an extremely difficult one for patients. There are many factors that play a role in increasing mastectomy rates – including improved reconstruction techniques, the assumption of improved survival, fear of radiation – and in any one patient, there may be many factors at work. We do a very extensive and detailed workup prior to surgery, which may involve additional imaging such as MRI or ultrasound, as well as additional biopsies. Even if the additional workup turns out to be negative, some women are in a sense spooked by the additional testing; they may choose mastectomy rather than take the chance of undergoing such extensive surveillance in the future. We do our best to explain that there is no survival advantage to the performance of a mastectomy, but many women are just as concerned about annual screening and surveillance as they are long-term survival
How can physicians increase patient acceptance of BCT at a time when mastectomy rates are rising?
Dr. Attai: A frank discussion about the risk of recurrence, survival statistics, and potential complications of both breast conservation and mastectomy is necessary; often multiple consultations or long discussions are needed. Recurrence rates, especially for women who are choosing breast conservation, are an important consideration. Many women are concerned that if the cancer recurs in the breast (after breast conservation therapy) that they will require mastectomy and that their reconstruction options will be limited if they have already undergone radiation therapy.
Dr. Zook: I think it is important for physicians to take the time and explain to patients the data we have to support breast conserving therapy and it’s equivalence to mastectomy. It is also important to discuss emotional aspects of losing a breast with the patient and how that may affect them down the road. With regards to radiation, I think it is important for patients to know that not everyone has to receive 6 weeks of daily radiation, which really has been the standard of care since the incorporation of breast conserving therapy. More data is being published and continuously updated on shortening the overall treatment time. Many women with early stage disease may be good candidates for APBI, shortening the treatment to only 5 days. I also discuss with my patients newer treatment planning techniques and devices like SAVI that help to minimize toxicity to normal tissues.
What role do oncoplastic surgical techniques, which are growing in popularity, play in BCT?
Dr. Zook: I do have a number of women who get oncoplastic surgeries as part of their breast conserving therapy. Usually this is in the setting where the surgeon has to remove a large portion of the breast due to tumor size or location that will leave a volume deficit translating into poorer cosmesis with breast conserving therapy. By doing an oncoplastic surgery, more women may be candidates for breast conserving therapy allowing better cosmetic outcomes in situations where mastectomy might have been recommended due to possible anticipation of poor cosmesis.
Dr. Attai: Various oncoplastic surgical techniques have allowed for the performance of larger volume lumpectomies with a good cosmetic result. As the adoption of these techniques grows, more women may be amenable to breast conservation instead of mastectomy.
Why do approximately 20% of women who opt for BCT continue to forego radiation therapy as part of their treatment? What can be done to address this?
Dr. Zook: I think the issue of distance and time required for treatment, as well as concerns about the short term as well as long term complications of treatment are factors. Education about side effects and about the importance of radiation is important. In addition, consideration for 5-day therapy may alleviate the concerns of some women related to time commitment for treatment or travel distance.
Dr. Attai: Certainly, time commitment and perceived danger of radiation are factors in which women consider when they decide to forego radiation. There have been studies showing that shorter treatment times with regards to whole breast irradiation is well tolerated and give equivalent outcomes to the standard 6 weeks of radiation. Also, APBI is very appealing to women because of the 5 day treatment course, with minimal to no toxicity to the skin, heart and lung compared with whole breast radiotherapy.
I think to address this issue, radiation oncologists need to discuss with their referring physicians who they deem good candidates for the shortened treatment times for whole breast radiation as well as partial breast irradiation. Since there is a range of accepted standards with regards to breast radiotherapy, each radiation oncologist is going to have their own opinions about who is appropriate for hypofractionated whole breast radiotherapy and partial breast irradiation. It is important to have open and clear communication between all of the members of the breast team (i.e. breast surgeons and medical oncologists) about who may be appropriate for the shortened treatments. I think it is also important that each patient have a consultation with a radiation oncologist to discuss radiation, even if they ultimately choose not to undergo therapy.
Dr. Attai is a board-certified surgeon practicing in Southern California. Since 2004, she has focused her career exclusively on the care of patients with benign and malignant breast conditions. In 2012, she was named a “Top Doctor” by U.S. News and World Report.
Dr. Zook is an assistant professor of radiation oncology at Indiana University Health in Indianapolis. Her areas of interest include breast cancer, APBI, IMRT and 3D conformal radiotherapy.