As we find ourselves approaching another Breast Cancer Awareness Month, we are reminded how far we have come in the diagnosis and care of patients with breast disease. Those of us with the privilege and duty to care for these patients are also reminded how much we have yet to achieve. Unfortunately, there are approximately 192,000 new cases of breast cancer in the United States per year. The number of deaths from the disease are over 40,000 per year. Based on rates from 2004-2006 approximately 12 percent (or one in eight) of women born will have breast cancer some time in their lifetime.

 

Screening is still our best hope of finding breast cancer early. This includes screening mammography, ultrasonography and physical examination. When a new palpable mass is identified on a woman's breast exam, a full workup is performed. Generally speaking, it is of consensus these days that core biopsies are the recommended next step. Surgical biopsies are more painful, deforming and expensive. Stereotactic core needle biopsies average 50 minutes and save an estimated $1,600 compared to open surgical biopsies. Core needle biopsy can also be performed via ultrasound guidance. An ultrasound-guided biopsy can even evaluate enlarged lymph nodes and lesions near the chest wall. It also tends to be more comfortable than stereotactic biopsy and generally less expensive. However, clustered calcifications cannot be well visualized with ultrasound and are best done by stereotactic means. Recently, MRI guided core biopsies have also become more common due to the increasing use of MRI in high risk patients.

 

In those cases of suspicious lesions on diagnostic studies whose core biopsy pathology is benign, an open excisional biopsy is sometimes indicated. This can be done with needle localization or intraoperative ultrasound guidance. If a malignant diagnosis is made by core biopsy, more and more frequently a bilateral breast MRI is performed to determine the true size of the lesion. It can also give information on lymph node involvement and any disease in the contralateral breast. Unfortunately, MRI specificity varies from 30-90% with frequent false positives.

 

Once diagnosed with a malignancy, women less than 50 years of age are now being referred for genetic testing. Inherited BRCA gene mutations however are responsible for less than 10% of breast cancers. The indication for BRCA testing include women diagnosed with breast cancer before the age of 50, or with first degree relatives with breast cancer prior to the age of 50. As well, patients with ovarian cancer at any age and any male breast cancer patient should be tested. Women with a BRCA mutation have a 33% to 50% risk for developing breast cancer by the age of 50. These days patients with the BRCA mutation without breast cancer have several options of risk reducing steps, including the use of Tamoxifen or Evista. There are even some who may elect for prophylactic bilateral mastectomy. Of course this may be the procedure of choice in a patient with BRCA and a unilateral breast cancer.

 

Once a diagnosis of a malignancy is made, breast conserving therapy has become the treatment of choice in early stage breast cancer for the last 15 years. This had been the consensus statement by the National Institute of Health in 1991. However, this is often influenced by physician bias, patient age, patient fear of radiation, availability of therapy and fear of recurrence.

 

There are several clinical conditions that limit breast conservation, such as size of tumor, extensive microcalcification, in addition to invasive cancer, early stage pregnancy and contraindication to radiation. Recently, accelerated partial breast irradiation has had a growing interest. This is delivered over a five day period by a balloon inserted at the time of a lumpectomy. This Mammosite balloon is removed easily after the fifth day. Thus far, approximately 32,000 women have been treated with the five year data looking very encouraging, with theoretical advantages being obvious. The theoretical disadvantage principally is the possibility occult foci of cancer not being treated adequately. Multi center randomized clinical trials continue to study this and its long term efficacy. 

 

Another way we have managed to limit our invasive treatment of breast malignancy is with sentinel lymph node biopsy. Axillary staging remains an important part of breast cancer surgery as lymph node metastasis remains an important prognostic factor. By the use of lymphoscintigraphy, a single or multiple sentinel lymph node can be identified and removed, avoiding a more extensive axillary dissection. The morbidity including nerve damage and lymphedema of axillary dissection can be better avoided. Sentinel lymph node biopsy can sometimes be done under local anesthesia, offering even fewer complications. A negative sentinel lymph node biopsy holds a better than 90% likelihood of a negative node status.

 

We continue to make strides slowly but with persistence. New technologies and research will hopefully bring us to a time where our efforts will affect the statistics in a meaningful way. It is what we strive for and our patients depend on. For more information feel free to contact Dr. Keller at 407-870-0808.