Breast Conserving Surgery: Has the Standard of Care Enhanced Outcomes for Patients?

Background. Breast conserving surgery followed by whole breast irradiation is widely accepted as standard of care for early breast cancer. Addition of a boost dose to the initial tumor area further reduces local recurrences. We investigated the dosimetric benefits of a simultaneously integrated boost (SIB) compared to a sequential boost to hypofractionate the boost volume, while maintaining normofractionation on the breast.Methods. For 10 patients 4 treatment plans were deployed, 1 with a sequential photon boost, and 3 with different SIB techniques: on a conventional linear accelerator, helical TomoTherapy, and static TomoDirect. Dosimetric comparison was performed.Results. PTV-coverage was good in all techniques. Conformity was better with all SIB techniques compared to sequential boost (P= 0.0001). There was less dose spilling to the ipsilateral breast outside the PTVboost (P= 0.04). The dose to the organs at risk (OAR) was not influenced by SIB compared to sequential boost. Helical TomoTherapy showed a higher mean dose to the contralateral breast, but less than 5 Gy for each patient.Conclusions. SIB showed less dose spilling within the breast and equal dose to OAR compared to sequential boost. Both helical TomoTherapy and the conventional technique delivered acceptable dosimetry. SIB seems a safe alternative and can be implemented in clinical routine.

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Radiation therapy after breast-conserving surgery: When are we missing the mark?

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.27_suppl.43 ◽

2012 ◽

Vol 30 (27_suppl) ◽

pp. 43-43

Author(s):

Mohammed Nassif ◽

Nora Trabulsi ◽

Kristen Reidel ◽

Sarkis H. Meterissian ◽

Robyn Tamblyn ◽

...

Keyword(s):

Advanced Disease ◽

Postoperative Radiotherapy ◽

Standard Of Care ◽

Breast Conserving Surgery ◽

Administrative Claims ◽

Cancer Registry Data ◽

Chemotherapy Administration ◽

Patient Diagnosis ◽

Physician Characteristics ◽

Wide Dissemination

43 Background: Postoperative radiotherapy (RT) after breast conserving surgery (BCS) represents the standard of care for local control of breast cancer (BC). Despite wide dissemination of clinical guidelines, variations in practice persist. Our objective was to identify patient, disease, and physician characteristics that predict lack of consideration for RT after BCS. Methods: Cancer registry data and administrative claims for all BCs diagnosed in Quebec from 1998 to 2005 were collected. Receipt of a consultation for RT in women with non-metastatic BC treated with BCS was measured. Multivariate logistic regression was used to assess the association between patient, disease, and physician characteristics and having an RT consult. Results: 27,483 women were included. Mean age was 59 years, 76.5% had no comorbidities, and 27.6% had stage III BC. Overall, 90.1% of women were considered for RT within 1 year of diagnosis. Patients at age extremes were less likely to be considered as compared to women 50-69: those 30-49, 70-79 and 80+ had odds ratios (OR) of 0.82 (CI 0.73-0.93), 0.54 (CI 0.48-0.61) & 0.11 (CI 0.09-0.12), respectively. Women with any ER visit and women with a hospitalization (unrelated to BC) had 15% and 17% lower odds of having an RT consult, respectively. In patients with advanced disease, receiving a consultation for chemotherapy within 4 months of BCS increased the likelihood of also being considered for RT within 1 year (OR 1.54, CI 1.19-2.00). Increases in physician BCS volume in the year prior to patient diagnosis increased the chance of their patient receiving an RT consult by 7% for every additional 10 BCS performed. Conclusions: Patient age, use of non- BC-related health services and physician volume of BCS predicts use of RT. Guideline deviations in chemotherapy administration also predicts variation in RT use.

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Appropriate treatment receipt after breast-conserving surgery

Current Oncology ◽

10.3747/co.25.4117 ◽

2018 ◽

Vol 25 (6) ◽

Cited By ~ 1

Author(s):

K. Guidolin ◽

M. Lock ◽

K. Vogt ◽

J. A. McClure ◽

J. Winick-Ng ◽

...

Keyword(s):

Breast Cancer ◽

Standard Of Care ◽

Breast Conserving Surgery ◽

Income Quintile ◽

Appropriate Treatment ◽

Increased Risk ◽

Breast Care ◽

High Comorbidity ◽

Incomplete Treatment ◽

Treat Breast Cancer

Background Breast-conserving surgery (bcs) and radiation therapy (rt) are the standard of care for early breastcancer, although some women receive ipsilateral mastectomy or adjuvant tamoxifen, both of which can be appropriate alternatives to rt. Objectives of the present study were to determine the proportion of women who are treated appropriately after bcs and to identify factors associated with non-receipt of rt.Methods This retrospective cohort study used Ontario data linked at the Institute for Clinical and Evaluative Sciences to examine 33,718 patients who received bcs during 2004–2010. Primary outcome was rt receipt. The ipsilateral mastectomy rate and patient, surgeon, and setting variables were measured.Results Of the study patients, 86.1% received either rt or completion mastectomy; in the cohort less than 70 years of age, 90.8% received rt or completion mastectomy. Among patients less than 70 years of age, 3 risk factors for nonreceipt of rt were identified: age less than 46 years, treatment in a non-academic institution, and earlier year of initial bcs. Additionally, in the overall cohort, rt non-receipt was associated with high comorbidity, more than 40 km to the cancer centre, income quintile, and breast care specialization.Conclusions In Ontario, 90.8% of patients less than 70 years of age are appropriately treated for early breast cancer; approximately 1 in 10 do not receive rt or completion mastectomy. Based on those findings, women less than 46 years of age might be at increased risk of recurrence and death because of incomplete treatment. It also appears that academic centres more effectively treat breast cancer; however, breast cancer care appears to be improving over time in Ontario.

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MarginProbe Radiofrequency Spectroscopy with Intraoperative Pathology Assessment: Synergistic, or Redundant?

10.21203/rs.3.rs-378438/v1 ◽

2021 ◽

Author(s):

Fred Qafiti ◽

Christina Layton ◽

Kerry-Ann McDonald

Keyword(s):

Tumor Size ◽

Chart Review ◽

Retrospective Chart Review ◽

Standard Of Care ◽

Breast Conserving Surgery ◽

Invasive Cancer ◽

Relative Reduction ◽

Consensus Guideline ◽

Positive Margins ◽

Incremental Value

Abstract Background:Published MarginProbe (MP) data reports ≥50% reduction in positive lumpectomy margins. Standard of care (SOC) in our facility uses intraoperative pathologic gross assessment for invasive cancer. We sought to determine if adjunctive use of MP would provide incremental value over gross assessment alone. Methods:This is a single-site, single-surgeon retrospective chart review of 86 consecutive lumpectomies with MP from 12/2018–11/2019. Margins were considered positive using SSO/ASTRO “no ink on tumor” consensus guideline for invasive cancer, and SSO/ASTRO/ASCO consensus guideline of 2mm or greater for pure DCIS. Significance was measured using Fisher’s exact two-tailed test.Results:76 patients (7 bilateral, 3 unilateral/multi-focal) yielded 86 lumpectomies for inclusion. Mean age was 69.8 and mean tumor size was 1.09cm. 68 invasive cancers were assessed using adjunct MP and gross assessment while 18 DCIS cases utilized MP only. Among all cases, gross assessment alone reduced positive margins from 27.9% to 19.8% (29.2% relative reduction, p=0.28). Utilizing both modalities in tandem, positive margins decreased from 27.9% to 9.3% (66.7% relative reduction, p<0.01) representing a 46.9% relative reduction versus gross assessment alone. Main specimen tissue volume was 27.1cc. After gross assessment and MarginProbe evaluation, there was additional excised volume that averaged 2.9 cc. Total averaged excised volume was 33 cc. This compares to the reported 40-60 cc average in multiple studies.Conclusion:Adjunctive use of MP with gross assessment maximizes reduction of positive margins during breast conserving surgery while minimizing impact on specimen volumes.

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Recurrence and mortality after breast-conserving surgery without radiation

Current Oncology ◽

10.3747/co.26.5225 ◽

2019 ◽

Vol 26 (6) ◽

Author(s):

K. Guidolin ◽

M. Lock ◽

K. Vogt ◽

J. A. McClure ◽

J. Winick-Ng ◽

...

Keyword(s):

Breast Cancer ◽

Protective Effect ◽

Randomized Trials ◽

Primary Outcome ◽

Standard Of Care ◽

Breast Conserving Surgery ◽

Cohort Size ◽

Hazard Ratios ◽

High Comorbidity ◽

Cancer Studies

Background Breast-conserving surgery (bcs) and radiation therapy (rt) are the standard of care for early breast cancer; studies have demonstrated that adjuvant rt confers a protective effect with respect to recurrence, although no randomized trials have shown a survival benefit.Methods This retrospective cohort study used Ontario data linked through ices to examine patients treated for breast cancer between 1 April 2007 and 31 March 2014. The primary outcome was death or recurrence. Outcomes were compared between patients who did and did not receive rt.Results The total cohort size was 26,279. The hazard ratios (hrs) for various outcomes were significantly higher for patients who did not receive rt than for patients who did: recurrence or death combined [hr: 2.49; 95% confidence interval (ci): 2.25 to 2.75], recurrence (hr: 2.33; 95% ci: 1.91 to 2.84), and death (hr: 2.28; 95% ci: 2.03 to 2.56). The hr for death was 1.81 (95% ci: 1.65 to 1.99) for patients having stage ii cancer compared with those having stage I disease. The hr for death was 1.97 (95% ci: 1.74 to 2.22) for patients having high comorbidity compared with those having little comorbidity.Conclusions Adjuvant rt carries a protective effect with respect to recurrence and survival in patients with earlystage breast cancer. That survival benefit has not been appreciated in previous randomized trials and underscores the importance of rt as a component of breast cancer treatment.

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Moderate hypofractionation remains the standard of care for whole-breast radiotherapy in breast cancer: Considerations regarding FAST and FAST-Forward

Strahlentherapie und Onkologie ◽

10.1007/s00066-020-01744-3 ◽

2021 ◽

Author(s):

David Krug ◽

◽

René Baumann ◽

Stephanie E. Combs ◽

Marciana Nona Duma ◽

...

Keyword(s):

Breast Cancer ◽

Late Effects ◽

Late Toxicity ◽

Standard Of Care ◽

Breast Conserving Surgery ◽

Breast Radiotherapy ◽

Recurrence Rates ◽

Whole Breast Radiotherapy ◽

The Difference ◽

Moderate Hypofractionation

AbstractModerate hypofractionation is the standard of care for adjuvant whole-breast radiotherapy after breast-conserving surgery for breast cancer. Recently, 10-year results from the FAST and 5‑year results from the FAST-Forward trial evaluating adjuvant whole-breast radiotherapy in 5 fractions over 5 weeks or 1 week have been published. This article summarizes recent data for moderate hypofractionation and results from the FAST and FAST-Forward trial on ultra-hypofractionation. While the FAST trial was not powered for comparison of local recurrence rates, FAST-Forward demonstrated non-inferiority for two ultra-hypofractionated regimens in terms of local control. In both trials, the higher-dose experimental arms resulted in elevated rates of late toxicity. For the lower dose experimental arms of 28.5 Gy over 5 weeks and 26 Gy over 1 week, moderate or marked late effects were similar in the majority of documented items compared to the respective standard arms, but significantly worse in some subdomains. The difference between the standard arm and the 26 Gy of the FAST-Forward trial concerning moderate or marked late effects increased with longer follow-up in disadvantage of the experimental arm for most items. For now, moderate hypofractionation with 40–42.5 Gy over 15–16 fractions remains the standard of care for the majority of patients with breast cancer who undergo whole-breast radiotherapy without regional nodal irradiation after breast-conserving surgery.

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Image-Guided Localization Techniques for Surgical Excision of Non-Palpable Breast Lesions: An Overview of Current Literature and Our Experience with Preoperative Skin Tattoo

Journal of Personalized Medicine ◽

10.3390/jpm11020099 ◽

2021 ◽

Vol 11 (2) ◽

pp. 99

Author(s):

Gianluca Franceschini ◽

Elena Jane Mason ◽

Cristina Grippo ◽

Sabatino D’Archi ◽

Anna D’Angelo ◽

...

Keyword(s):

Early Stage ◽

Cost Effective ◽

Standard Of Care ◽

Surgical Excision ◽

Breast Conserving Surgery ◽

Advantages And Disadvantages ◽

Seed Localization ◽

Technological Developments ◽

Palpable Breast ◽

Best Localization

Breast conserving surgery has become the standard of care and is more commonly performed than mastectomy for early stage breast cancer, with recent studies showing equivalent survival and lower morbidity. Accurate preoperative lesion localization is mandatory to obtain adequate oncological and cosmetic results. Image guidance assures the precision requested for this purpose. This review provides a summary of all techniques currently available, ranging from the classic wire positioning to the newer magnetic seed localization. We describe the procedures and equipment necessary for each method, outlining the advantages and disadvantages, with a focus on the cost-effective preoperative skin tattoo technique performed at our centre. Breast surgeons and radiologists have to consider ongoing technological developments in order to assess the best localization method for each individual patient and clinical setting.

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The Evolving Role of Ultrasound Guided Percutaneous Laser Ablation in Elderly Unresectable Breast Cancer Patients: A Feasibility Pilot Study

BioMed Research International ◽

10.1155/2018/9141746 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Jacopo Nori ◽

Maninderpal Kaur Gill ◽

Icro Meattini ◽

Camilla Delli Paoli ◽

Dalmar Abdulcadir ◽

...

Keyword(s):

Breast Cancer ◽

Laser Ablation ◽

Residual Disease ◽

Performance Status ◽

Standard Of Care ◽

Breast Conserving Surgery ◽

Breast Cancers ◽

Breast Cancer Patients ◽

Small Breast

Background and Objectives. Breast-conserving surgery represents the standard of care for the treatment of small breast cancers. However, there is a population of patients who cannot undergo the standard surgical procedures due to several reasons such as age, performance status, or comorbidity. Our aim was to investigate the feasibility and safety of percutaneous US-guided laser ablation for unresectable unifocal breast cancer (BC). Methods. Between December 2012 and March 2017, 12 consecutive patients underwent percutaneous US-guided laser ablation as radical treatment of primary inoperable unifocal BC. Results. At median follow-up of 28.5 months (range 6-51), no residual disease or progression occurred; the overall success rate for complete tumor ablation was therefore 100%. No significant operative side effects were observed, with only 2 (13.3%) experiencing slight to mild pain during the procedure, and all patients complained of a mild dull aching pain in the first week after procedure. Conclusions. Laser ablation promises to be a safe and feasible approach in those patients who are not eligible to the standard surgical approach. However, longer follow-up results and larger studies are strongly needed.

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Early Breast Cancers During Pregnancy Treated With Breast-Conserving Surgery in the First Trimester of Gestation: A Feasibility Study

Frontiers in Oncology ◽

10.3389/fonc.2021.723693 ◽

2021 ◽

Vol 11 ◽

Author(s):

Concetta Blundo ◽

Massimo Giroda ◽

Nicola Fusco ◽

Elham Sajjadi ◽

Konstantinos Venetis ◽

...

Keyword(s):

Breast Cancer ◽

Early Stage ◽

Standard Of Care ◽

First Trimester ◽

Breast Conserving Surgery ◽

Breast Cancers ◽

First Trimester Of Pregnancy ◽

Isolated Local Recurrence ◽

Age Range

Breast cancer is the most common malignancy occurring during gestation. In early-stage breast cancer during pregnancy (PrBC), breast-conserving surgery (BCS) with delayed RT is a rational alternative to mastectomy, for long considered the standard-of-care. Regrettably, no specific guidelines on the surgical management of these patients are available. In this study, we investigated the feasibility and safety of BCS during the first trimester of pregnancy in women with early-stage PrBC. All patients with a diagnosis of PrBC during the first trimester of pregnancy jointly managed in two PrBC-specialized Centers were included in this study. All patients underwent BCS followed by adjuvant radiotherapy to the ipsilateral breast after delivery. Histopathological features and biomarkers were first profiled on pre-surgical biopsies. The primary outcome was the isolated local recurrence (ILR). Among 168 PrBC patients, 67 (39.9%) were diagnosed during the first trimester of gestation. Of these, 30 patients (age range, 23-43 years; median=36 years; gestational age, 2-12 weeks; median=7 weeks; median follow-up time=6.5 years) met the inclusion criteria. The patients that were subjected to radical surgery (n=14) served as controls. None of the patients experienced perioperative surgical complications. No ILR were observed within three months (n=30), 1 year (n=27), and 5 years (n=18) after surgery. Among the study group, 4 (12.3%) patients experienced ILR or new carcinomas after 6-13 years, the same number (n=4) had metastatic dissemination after 3-7 years. These patients are still alive and disease-free after 14-17 years of follow-up. The rate of recurrences and metastasis in the controls were not significantly different. The findings provide evidence that BCS in the first trimester PrBC is feasible and reasonably safe for both the mother and the baby.

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Consensus statement on tumour bed localization for radiation after oncoplastic breast surgery

Current Oncology ◽

10.3747/co.27.5977 ◽

2020 ◽

Vol 27 (3) ◽

Author(s):

T. Tse ◽

S. Knowles ◽

J. Bélec ◽

J.M. Caudrelier ◽

M. Lock ◽

...

Keyword(s):

Locally Advanced Breast Cancer ◽

Locally Advanced ◽

Standard Of Care ◽

Breast Conserving Surgery ◽

Careful Consideration ◽

Adjuvant Radiation ◽

Oncoplastic Breast Surgery ◽

Modified Delphi ◽

Radiation Oncologists ◽

Boost Radiation

Background: Oncoplastic surgery (OPS) is becoming the new standard of care for breast-conserving surgery. OPS has led to some challenges with adjuvant radiation, particularly when accurate tumour bed (TB) delineation is needed for focused radiation (i.e. accelerated partial breast radiation or boost radiation). Currently, there on no guidelines on tumour bed localization for adjuvant targeted radiation after OPS. Methods: A modified-Delphi method was used to establish consensus amongst a panel of 20 experts in surgical and radiation oncology at the Canadian Locally Advanced Breast Cancer National Consensus (LABCNC) Group and in subsequent online surveys. Results: The main recommendations are as follows: 1) Surgical clips are necessary and should, at a minimum, be placed along the four side walls of the cavity plus one to four clips at the posterior margin if necessary; 2) Operative reports should include pertinent information to help guide the radiation oncologists; 3) Breast surgeons and radiation oncologists should have a basic understanding of OPS techniques and work on “speaking a common language”; and 4) Careful consideration is needed when determining the value of targeted radiation, like boost, in higher level OPS procedures with extensive tissue rearrangement. Conclusion: The panel developed a total of six recommendations on TB delineation for more focused radiation therapy after OPS, with over 80% agreement on each statement. These are summarized along with the corresponding evidence and/or expert opinion.

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