I just wanted to mention ductal carcinoma in situ. This is a very controversial area in terms of management. The choices, I think, are mainly mastectomy with no axillary dissection. This is only in those cases where there is no invasive disease noted versus a lumpectomy and radiation versus a lumpectomy with no other therapy. There’s a randomized trial really looking at these three various options and the lumpectomy alone had an increased incidence of local recurrence. There are certainly places like Van Nuys, California and other places who are doing very careful pathology, requiring larger margins and with smaller tumors are able to do lumpectomy alone. I think you really have to recreate some of those pathologic techniques and surgical techniques to get those kind of results and so I would not probably apply a lumpectomy alone to all patients who have ductal carcinoma in situ.

Lobular carcinoma in situ I look at as just a marker for risk not much unlike family history or other risk factors and I think that diagnosis warrants closer surveillance. Only in those patients who have other high risk or have breasts that are really very difficult for surveillance, don’t mammogram well, are too dense for accurate mammography or ultrasound doesn’t work or whatever, they have lots of lumps and bumps, would I consider bilateral mastectomy.

Let’s talk a little bit about the approach to patients who have been diagnosed with invasive carcinoma, ductal carcinoma, medullary carcinoma, lobular carcinoma. Really the approach is the same. The two approaches to local control are either a modified radical mastectomy or a lumpectomy with radiation and an axillary sampling or dissection.

A caveat to that has been the sentinel node dissection. Usually a patient with a smaller tumor and a tumor that has been diagnosed by needle aspirate or biopsy but not been excised you can put dye or technetium or something into the tumor bed, trace it to the first axillary node, dissect that and in the appropriately selected patients, that should be 95% predictive as to what the axillary status is. So if it’s negative in the axillary nodes, it’s 95% that the rest of the nodes will be negative also and further dissection is not necessary. If it’s positive, there’s about a 3% chance that the rest of the next axillary nodes will be negative but it requires them to go and dissect the node if it’s positive.

This is a look at mastectomy versus lumpectomy radiation and axillary dissection. This is at eight year followup. The earliest publication with followup is now at 20 years. Similar studies have reproduced these exact results in Europe and it really shows that there’s no difference in overall survival in patients treated with these two different local options. The deal is that this is really an option for the woman in terms of how she wants to approach this and it shouldn’t make a difference in overall outcome.

There are a few reasons not to do a lumpectomy and radiation. If you’ve got a very large tumor in a small breast, you’re not going to get a very good cosmetic result and it probably isn’t the right thing to do. If there’s a multifocal tumor throughout the breast, doing lumpectomy is not really feasible. If the breast is very dense, a lot of other pathology in the breast, it may be that that won’t lend to good surveillance in the future of that radiated breast which will increase the fibrosis and density and perhaps mastectomy is the best thing to do. Very rarely there will be patients with such severe underlying heart disease or lung disease that you won’t think they can tolerate the radiation but that’s very rare.

If the patient does choose for mastectomy, it certainly should be discussed with the patient’s various reconstruction options. Most of this reconstruction is getting done at the time of initial surgery if the patient doesn’t appear to have advanced local disease.

Just to talk about staging a little bit because really everything we do is based on the predictive value of the staging and a few other predictive features. Staging is based on the tumor node and metastasis system. The tumor is divided between T1 through T4. A T1 lesion is less than 2 cm, T2 between 2 and 5 cm, T3 more than 5 cm and a T4 lesion is a lesion that extends into the muscle or into the skin. It also includes inflammatory breast cancer – breast cancer that presents as a red inflamed breast, has an erysipeloid kind of appearance and if you biopsy that, often their dermal lymphatics will show tumor cells within them.

Lifestyle is becoming increasingly recognized as having risk for breast cancer and smoking and alcohol intake has been related to an increased risk. Now there are a couple of studies that show vigorous exercise, particularly in the teenage years, may markedly decrease the risk for breast cancer.

As I noted there are four cloned genes that we know about that predispose to breast cancer. All of these conferring risk in an autosomally dominant way: BRAC-1, BRAC-2 – these are the breast and ovarian syndromes, ataxia telangiectasia. If the patients are homozygous, they don’t live to a very long life but if they’re heterozygous, they probably do have an increased risk for breast cancer and the importance of identifying these patients are that they are at great risk for risks of radiation and maybe increased surveillance by mammography is a bad thing to do for these patients. It’s a fairly rare thing. P-53 is the Li-Fraumeni syndrome. It’s related to increased incidence of sarcomas and breast cancers and other tumors.

Well, what is the standard screening for breast cancer? Certainly self exam, I think, should be incorporated although sometimes people argue whether studies show that this is useful. The clinical physical exam is of use and the main imaging technique for screening is mammogram. Breast self-exam in a couple of old prospective studies has shown that when used in a consistent way that it will lead to diagnosis of tumors that are more likely to be smaller in the Stage I category and with no positive nodes.

These are the American Cancer Society guidelines for early detection of breast cancer and the NIH has come more into line now with these guidelines. A few years ago they were not so aligned but from age 20-39, clinical breast exam by a physician or nurse every three years and a monthly breast self exam. Age 40 or older, and this is the difference, annual mammography, annual clinical breast exam and monthly breast self exam. Prior to this, the NIH had not recommended mammograms until age 50.

Now, these are for people at standard risk and patients who have a strong family history or look like they may be in a family at great risk, I usually start some sort of surveillance mammography about ten years prior to the onset of maybe the first degree relative that had breast cancer or something like that.

If there is an abnormality on the mammogram or a palpable lesion, what are the biopsy techniques? For mammographic lesions, stereotactic biopsies are very useful. It’s quite accurate in getting the needle right into the lesion on mammogram. Sometimes when you put these wires in for localization, you can be off by quite a bit. That’s why it’s so important to do the specimen mammogram after the excisional biopsy when the wires have been placed.

Fine needle aspirates, I think, are very useful. Particularly if you have a larger lesion you can localize it. To do a fine needle aspirate, you haven’t then been in there surgically and when you have the diagnosis you can concretely sit down and talk about all the surgical options. When people have a localized lesion, I think a fine needle aspirate is a nice way to go. If it’s not positive then you’re going to have to do an excisional biopsy but it often is positive or a needle directed biopsy.

Breast cancer is the most common diagnosed cancer in women. It’s not the most common cause of cancer death in women. That goes to lung cancer which occurs much less frequently than breast cancer but the morbidity is a great deal higher. These numbers have remained fairly stable over time. The mortality has also remained fairly stable although in some subgroups it has decreased. In women of higher socioeconomic status, more of those patients seem to be not having recurrent breast cancer or being cured, perhaps because of the effect of early detection through mammogram and education.
There are a number of risk factors that have been noted for breast cancer. The greatest risk factor is probably age and the peak incidence of breast cancer occurs between the fifth and sixth decade. If you’ve had a previous history of breast cancer in one breast, you’re certainly at increased risk to develop a second breast cancer either in the breast that’s had lumpectomy and radiation or in the other breast. Family history clearly puts you at some risk and depending on the number of members of the family that are positive and the closeness of the relationship dictates the risk. If you have a first degree relative that had bilateral premenopausal breast cancer, you probably have a lifetime risk of breast cancer that comes close to 50%.
Of course, now there are genes that we’ve identified that are inherited in an autosomal dominant way that confer lifetime risk in the 80% range and these are BRAC-1 and BRAC-2 genes. Other genes that are associated with breast cancers, P53, abnormality in the P53 gene and the ataxia telangiectasia gene that’s not been cloned.
Anything that prolongs cycling or the estrogenic cycling of the breast tissue probably is related to a slight increased risk of breast cancer. So never having a pregnancy or having a late age for first pregnancy, early menarche or late menopause all confer some increased risk for breast cancer. Prior radiation to the chest is clearly an increased risk for breast cancer particularly if it’s a lose dose radiation that occurs in the prepubertal years.