Management of Breast Cancer with Breast Conserving Surgery

• Once a patient undergoes breast-conserving surgery:
  • The pathology report is reviewed to determine any need for additional surgery
  • If the sentinel node biopsy was negative:
    • No additional axillary surgery is warranted
  • Margins assessed next:
    • Historically, the definition of what was considered an adequate margin in patients undergoing breast-conserving surgery was left to the interpretation of the treating physicians
    • In 2013, the Society of Surgical Oncology and the American Society for Radiation Oncology released consensus guidelines to assist physicians and patients in decisions regarding margins:
      • These guidelines were based on:
        • A meta-analysis of 33 studies evaluating in-breast tumor recurrence (IBTR) in relation to margin width
      • The results of the meta-analysis reported:
        • Positive margins were associated with 2-fold risk of IBTR:
          • Routine re-excision is recommended for those patients
        • For those with negative margins (defined as “no ink on tumor”), the meta-analysis reported that:
          • Increasing margin widths were not associated with a reduction in IBTR.
  • Is the patient a candidate for adjuvant therapy?
    • The 21-gene recurrence assay:
      • Has been shown to accurately predict risk of distant recurrence and benefit of adjuvant chemotherapy:
        • In women with ER positive tumors
    • Adjuvant chemotherapy is a category 1 recommendation for women with:
      • ER negative tumors greater than 1 cm
  • Does this patient need genetic studies?
    • The incidence of BRCA mutations in women with triple negative breast cancers:
      • Ranges in the literature from 10% to 31%
    • Current guidelines state that women who present with triple negative histology prior to age 60 should be considered for testing

• References
  • Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole breast irradiation in Stage I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88(3):553–564.
  • Breast Cancer (version 1.2018). National Comprehensive Cancer Network website. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed October 18, 2019.
  • Greenup R, Buchanan A, Lorizio W, Rhoads K, Chan S, Leedom T, et al. Prevalence of BRCA mutations among women with triple negative breast cancer in a genetic counseling cohort. Ann Surg Oncol. 2013;20:3254-3258.
  • Genetic/Familial High Risk Assessment: Breast and Ovarian (version 2.2019). National Comprehensive Cancer Network website. https://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf. Accessed October 18, 2019.

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