Balancing Evidence and Clinical Balancing Evidence and Clinical Practice in the Treatment of Practice in the Treatment of Localized Breast Cancer Localized Breast Cancer May 5, 2006 May 5, 2006 Deborah Hamolsky MS, RN : DCIS Deborah Hamolsky MS, RN : DCIS Carol Franc Buck Breast Care Center Carol Franc Buck Breast Care Center UCSF Comprehensive Cancer Center UCSF Comprehensive Cancer Center Jane Armer PhD, RN : Jane Armer PhD, RN : Lymphedema Lymphedema University of Missouri University of Missouri - - Columbia Columbia School of Nursing School of Nursing Deena Deena Dell MSN, RN, AOCN, BC : Moderator Dell MSN, RN, AOCN, BC : Moderator Decision Tools/Session Moderator Decision Tools/Session Moderator Fox Chase Cancer Center Fox Chase Cancer Center
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Balancing Evidence and Clinical Balancing Evidence and Clinical Practice in the Treatment of Practice in the Treatment of
Localized Breast CancerLocalized Breast CancerMay 5, 2006May 5, 2006
Deborah Hamolsky MS, RN : DCISDeborah Hamolsky MS, RN : DCISCarol Franc Buck Breast Care Center Carol Franc Buck Breast Care Center
UCSF Comprehensive Cancer CenterUCSF Comprehensive Cancer Center
Jane Armer PhD, RN : Jane Armer PhD, RN : LymphedemaLymphedemaUniversity of Missouri University of Missouri -- Columbia Columbia
School of NursingSchool of Nursing
DeenaDeena Dell MSN, RN, AOCN, BC : ModeratorDell MSN, RN, AOCN, BC : ModeratorDecision Tools/Session ModeratorDecision Tools/Session Moderator
Fox Chase Cancer Center Fox Chase Cancer Center
DuctalDuctal Carcinoma in Situ (DCIS): Carcinoma in Situ (DCIS): Controversies in CareControversies in Care
Confinement of malignant Confinement of malignant cells within the natural cells within the natural basement membrane of basement membrane of ductductIntraductalIntraductal, , nonnon--invasive, invasive, nonnon--infiltrating,infiltrating,stage 0 breast cancerstage 0 breast cancer
((breastcancerbreastcancer.org.org))Artist: Mary Kelso BrysonArtist: Mary Kelso Bryson
•• Surgery Surgery Lumpectomy (BCS) vs. Lumpectomy (BCS) vs. Mastectomy?Mastectomy?Sentinel Lymph Node Sentinel Lymph Node (SLN) (SLN) BxBx ??
•• Radiation therapy Radiation therapy None None whole breast (WBR)whole breast (WBR)vs. partial (PBR) vs. partial (PBR)
•• Rx recommendation Rx recommendation problems:problems:DCIS heterogeneous, no DCIS heterogeneous, no uniform gradinguniform gradingInaccuracy of size Inaccuracy of size measurement and measurement and limitations of imaginglimitations of imagingLong natural historyLong natural history(Sanders et al, 2005)(Sanders et al, 2005)Limited published clinical Limited published clinical trial datatrial data
Van Nuys Prognostic Index Van Nuys Prognostic Index Tumor size Tumor size •• Nuclear grade (low, intermediate, high)Nuclear grade (low, intermediate, high)•• Margin widthMargin width•• Presence, absence of Presence, absence of comedonecrosiscomedonecrosis
USC/VNPI USC/VNPI •• Addition of age as variableAddition of age as variable
(Silverstein, Mel 2003)(Silverstein, Mel 2003)
DCIS and MastectomyDCIS and MastectomyRecurrence with Recurrence with mastectomy 1mastectomy 1--2%2%
Mastectomy high cure Mastectomy high cure rate; can be seen as rate; can be seen as prophylactic prophylactic –– prevents prevents invasive ca.invasive ca.
2005 Mast vs. BCS meta2005 Mast vs. BCS meta--analysis 6 trials analysis 6 trials ––mastectomy decreases mastectomy decreases recurrence, no mortality recurrence, no mortality benefit benefit ((JatoiJatoi & & ProshanProshan, 2005), 2005)
How to decide?How to decide?-- ? risk of recurrence? risk of recurrence
-- ? risk of systemic ? risk of systemic disease and mortalitydisease and mortality
-- ? surgical risks and ? surgical risks and emotional outcomes of emotional outcomes of mastectomy with, without mastectomy with, without reconstructionreconstruction
(Fisher, 1998; (Fisher, 1998; JatoiJatoi & & ProshanProshan, 2005, 2005Personal communication L. Margolis, Personal communication L. Margolis, UCSF, 2006)UCSF, 2006)
Breast Conserving Surgery (BCS):Breast Conserving Surgery (BCS):Lumpectomy AloneLumpectomy Alone
Partial Breast Irradiation (PBI)Partial Breast Irradiation (PBI)
Techniques:Techniques:Brachytherapy Brachytherapy
-- multimulti--cathetercatheter-- balloon catheterballoon catheter-- mammositemammosite-- intraoperativeintraoperative RT with RT with linear accelerator or low linear accelerator or low energy xenergy x--raysrays-- 3D conformal RT3D conformal RT
(Rogers, 2004)(Rogers, 2004)
DCIS DCIS multicentricitymulticentricity& recurrence& recurrence6 studies: 24% of 374 pts. 6 studies: 24% of 374 pts.
(Margolis, L. , UCSF, personal (Margolis, L. , UCSF, personal communication 2006)communication 2006)
Not all pts. eligible for Not all pts. eligible for xRTxRT receive it (pt. choice, receive it (pt. choice, access)access)
Sentinel Lymph Node Biopsy in Sentinel Lymph Node Biopsy in DCIS: Balancing Benefit and RiskDCIS: Balancing Benefit and Risk
108 / 371 DCIS pts 1+SLN; 108 / 371 DCIS pts 1+SLN; ALND in 139 of 371 DCIS pts; 3 ALND in 139 of 371 DCIS pts; 3 pts with + pts with + LN’sLN’s (Yang et al, (Yang et al, 2005)2005)
High risk DCIS 9/76 had +SLN, High risk DCIS 9/76 had +SLN, 7/9 7/9 micrometsmicromets((KlauberKlauber--DeMoreDeMore et al, 2000)et al, 2000)
POSTMASTECTOMY MORTALITY POSTMASTECTOMY MORTALITY RISK is 1%!RISK is 1%!
Conclusions: Surgery and Whole Conclusions: Surgery and Whole Breast Irradiation (WBR) Breast Irradiation (WBR)
Conclusions: Partial Breast Conclusions: Partial Breast Irradiation (PBI) Irradiation (PBI)
1. Preference that patients be 1. Preference that patients be enrolled on protocol; continued enrolled on protocol; continued insufficient evidenceinsufficient evidence
2. Adequate surgeon training for 2. Adequate surgeon training for technique utilization in intratechnique utilization in intra--operative (IORT), balloon operative (IORT), balloon catheter, bead or seed catheter, bead or seed implants, shortened implants, shortened (accelerated) courses of (accelerated) courses of external beamexternal beam
3. Selection Criteria (off trial)3. Selection Criteria (off trial)Age Age >50>50IDC or DCISIDC or DCISTotal tumor size Total tumor size ≤≤2cm2cmNegative margins of at least Negative margins of at least 2mm2mmSLN / ALND negativeSLN / ALND negative
(The American Society of Breast (The American Society of Breast Surgeons, 2003; NCCN Practice Surgeons, 2003; NCCN Practice Guidelines v.2.2006)Guidelines v.2.2006)
Conclusions: Criteria to Include Conclusions: Criteria to Include Sentinel Lymph Node (SLN) BiopsySentinel Lymph Node (SLN) Biopsy
Biopsy SLN with mastectomy (cannot technically do Biopsy SLN with mastectomy (cannot technically do later if occult invasive disease)later if occult invasive disease)Not generally recommended for DCIS with breast Not generally recommended for DCIS with breast conserving surgery unless DCIS conserving surgery unless DCIS >5cm or >5cm or microinvasionmicroinvasion (controversial)(controversial)Insufficient data to include SLN for specific Insufficient data to include SLN for specific biological markers (grade, histology)biological markers (grade, histology)
(ASCO Guidelines, 2005, (ASCO Guidelines, 2005, PendasPendas et al, 2004; et al, 2004; JakubJakub et al, 2004, et al, 2004, NCCN Guidelines, 2006)NCCN Guidelines, 2006)
Future Directions and New Future Directions and New Questions in DCIS TreatmentQuestions in DCIS Treatment
Will surgical treatment Will surgical treatment always be necessary? always be necessary?
The role of adjuvant, The role of adjuvant, neoadjuvantneoadjuvant, therapy, therapy
Ongoing data collection Ongoing data collection re SLN, radiation therapyre SLN, radiation therapy
Biopsies in the Future Should Define Biopsies in the Future Should Define Disease Type, Treatment and Disease Type, Treatment and
Prevention ApproachPrevention Approach
DCIS and the Art of Supporting DCIS and the Art of Supporting Informed Patient DecisionsInformed Patient Decisions
Diagnosis, grade, extent Diagnosis, grade, extent of disease, ageof disease, ageDCIS treatment choices DCIS treatment choices •• Recurrence riskRecurrence risk•• Chance of invasive Chance of invasive
cancercancer•• Chance of cancer in Chance of cancer in
contralateralcontralateral breastbreast
Patient PreferencePatient PreferenceHow important isHow important is•• Keeping your breast?Keeping your breast?•• Minimizing chance of Minimizing chance of
having to deal with having to deal with breast cancer?breast cancer?