Introduction
Breast cancer is the most common cancer in women accounting for 266,000 new cancers in 2019 alone. It is the second most common cause of cancer-related mortality in women. It has been estimated that 12% of American women will be diagnosed with breast cancer during their lifetime (1/8) and 3.5% will die of the disease. The incidence of breast cancer increases with age. Male breast cancer accounts for 1% of all breast cancers.
Globally, breast cancer incidence rates are highest in North America and Northern Europe, and lowest in Asia and Africa. Studies of migration patterns to the United States are consistent with the importance of cultural and/or environmental changes. In general, incidence rates of breast cancer are greater in second-generation migrants and increase further in third- and fourth-generation migrants. Overall, breast cancer mortality rates have declined since 1975, attributable to the increased use of screening mammography and the aggressive use of adjuvant therapies. Despite having a lower incidence rate than white women, black women have a higher mortality rate that is attributable to both more advanced stage at diagnosis and higher stage-specific mortality.
Multiple risk factors have been associated with breast cancer. These include
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age and gender,
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family history and genetic factors,
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personal history of breast cancer,
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race and ethnicity,
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reproductive and hormonal factors,
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benign breast disease,
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lifestyle and dietary factors,
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exposure to ionizing radiation, and
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environmental factors.
Age and Gender
Both age and gender are among the strongest risk factors for breast cancer development. The female breast cancer incidence increases with age. Male breast cancer incidence is approximately 1%.
Family History and Genetic Factors
Family history is an important risk factor for breast cancer. However, a positive family history is only reported by 10%–15% of women with breast cancer. Most breast cancers, 85% are sporadic in nature.
The risk associated with having an affected first or second degree maternal or paternal relative is modulated by the age of both the case patient and the family member at diagnosis, and the number of female first-degree relatives with and without cancer. Specific genetic mutations that predispose to breast cancer are rare; only 5%–6% of all breast cancers are directly attributable to inheritance of a breast cancer susceptibility gene such as BRCA1, BRCA2, p53, ATM, PTEN, and other breast cancer–related actionable mutations. Once a patient is identified as a high risk for a genetic predisposition for breast cancer based on the personal history of cancer or the family history, the patient is referred for genetic counseling and possible genetic testing. Only about 5% of breast cancer patients will harbor an actionable breast cancer–related mutation. In this subset of patients, prophylactic surgical intervention might be indicated depending on the specific gene identified. The BRCA1 and BRCA2 are the most prevalent breast cancer–related genes and the following are considered “red flags” for the hereditary breast and ovarian cancer: breast cancer before age 50, ovarian cancer at any age, male breast cancer at any age, multiple primary cancers, and Ashkenazi Jewish ancestry.
Personal History of Breast Cancer
A personal history of invasive or in situ breast cancer increases the risk of developing an invasive breast cancer in the contralateral breast. With in situ lesions the 10-year risk of developing a contralateral invasive cancer is 5%. In women with invasive breast cancer the risk of developing contralateral breast cancer is 1% and 0.5% per year for premenopausal and postmenopausal women, respectively.
Benign Breast Disease
Nonproliferative breast lesions such as fibrocystic changes, solitary papilloma, and simple fibroadenoma are not associated with an increased risk for breast cancer. The more important precursors of noninvasive or invasive breast cancer are proliferative lesions, particularly those with cytologic atypia. The risk of invasive breast cancer is slightly increased (relative risk 1.3–2) for a proliferative lesion without atypia (complex fibroadenoma, moderate or florid hyperplasia, sclerosing adenosis, and intraductal papillomas). For a proliferative lesion with atypia (atypical lobular hyperplasia, atypical ductal hyperplasia, and atypical papillary lesion), the risk is higher (relative risk 4–6) and higher still (10-fold) when the atypia is multifocal.
Race and Ethnicity
In the United States, breast cancer is the most common cancer among women of every major ethnic group, although there are interracial differences. Given data from the American Cancer Society, the highest rates occur in whites. The rates are lower in blacks, Asian Americans/Pacific Islanders, Hispanic/Latina women, and American Indians/Alaska natives. These ethnic differences may be related to factors associated with lifestyle and socioeconomic status (e.g., access to diagnosis and treatment). Disparities in breast cancer survival may be attributed to race, genetic, and/or biologic factors.
Reproductive and Hormonal Factors
Prolonged exposure to and higher concentrations of endogenous estrogen increase the risk of breast cancer. The key reproductive factors that influence breast cancer risk are age at menarche, age at first live birth, age at menopause, and possibly parity and breastfeeding. Younger age at menarche and later age of menopause are associated with a higher risk of breast cancer (cumulative estrogen exposure). Nulliparous women are at increased risk for breast cancer compared with parous women; the relative risk ranges from 1.2 to 1.7. The younger a woman is at her first full-term pregnancy, the lower her breast cancer risk: A protective effect of breastfeeding has been shown in multiple case–control and cohort studies, the magnitude of which is dependent on the duration of breastfeeding and the confounding factor of parity. Other controversial areas include the risk of hormone replacement therapy, the use of oral contraceptives, and infertility treatments.
Lifestyle and Dietary Factors
Socioeconomic Status
Women of higher socioeconomic status are at greater risk for breast cancer, with as much as a twofold increase in incidence from lowest to the highest strata. However, it does not appear that socioeconomic status is an independent risk factor. Instead, the influence of socioeconomic status (educational, occupational, and economic level) is thought to reflect differing reproductive patterns with respect to parity, age at first birth, age at menarche, and utilization of screening mammography.
Geographic Residence
There are marked variations in breast cancer incidence and mortality among countries.
Weight
Weight and body mass index have opposite influences on postmenopausal as compared to premenopausal breast cancer (higher circulating levels of estrogens in women who have more adipose tissue that increases peripheral conversion of estrogen precursors to estrogen).
Physical Activity
Regular physical exercise appears to provide modest protection against breast cancer, but the relationship is complex, particularly in premenopausal women. The reduction in breast cancer risk seen with exercise may be mediated in part through weight control.
Alcohol
Moderate alcohol intake is associated with an increased risk of hormone receptor-positive breast cancer, and the effect appears to be additive with hormone replacement therapy.
Fat Intake
Several studies have shown a positive correlation between fat consumption and increased breast cancer risk. However, the results of case–control and prospective cohort studies have been mixed, possibly because of the limited range of dietary fat in the typical American diet and an interaction between reproductive variables, menopausal status, and fat intake.
Caffeine
A number of studies have failed to show any association between caffeine intake and breast cancer risk.
Smoking
The relationship between cigarette smoking and breast cancer is controversial and complicated by the interaction of smoking with alcohol and the endogenous hormonal influences that alter breast cancer risk. As part of a healthy lifestyle, patient should be advised to refrain from cigarette smoking as lung cancer the most common cause of cancer–related mortality in women.
Exposure to Ionizing Radiation
Exposure to ionizing radiation of the chest at a young age, as occurs with treatment of Hodgkin lymphoma or in survivors of atomic bomb or nuclear plant accidents, is associated with an increased risk of breast cancer. The most vulnerable ages appear to be between 10 and 14 years of age (the prepubertal years), but excess risk is seen in women exposed as late as 45 years of age. Whether there is a link between breast cancer and low levels of irradiation, such as those in diagnostic imaging tests, is controversial.
Environmental Factors
Organochlorines include polychlorinated biphenyls, dioxins, and organochlorine pesticides such as dichlorodiphenyltrichloroethane (DDT). These compounds are weak estrogens, highly lipophilic, and capable of persisting in body tissues for years. However, most large studies have failed to find an association.
The best defense against breast cancer is early detection to the extent that for stage I breast cancer the 10-year survival is 98.5%. The multidisciplinary approach is critical to maximize the breast cancer cure, including surgical oncology, medical oncology, radiation oncology, plastic surgery, and rehab oncology. The optimal treatment needs to be individualized taking into consideration the breast tumor characteristics, breast cancer stage, and the patient’s underlying comorbidities.
Role of Surgery in the Treatment of Breast Cancer
The role of surgery in the treatment of breast cancer has two main primary goals: extirpation of the breast tumor burden for local control and axillary lymph node assessment for staging purposes when indicated. As part of the multidisciplinary treatment, the role of chemotherapy or adjuvant endocrine therapy is systemic control and the role of adjuvant radiation therapy is local control. Each of the treatment strategies has associated side effects that need to be thoroughly discussed as part of the decision-making process. Though the most critical goal is to maximize the breast cancer cure and minimize the likelihood of local recurrence, quality of life issues need to be addressed. Given the state-of-the-art treatment available, active research, and increased breast cancer awareness, there are more than 3 million breast cancer survivors in the United States alone. The challenge for providers is to maximize the breast cancer cure while maintaining good quality of life.
Surgical Management of Breast Cancer
Overall, there are two main types of surgery for the treatment of breast cancer: breast conservation treatment (BCT) that may be referred to as lumpectomy, wide excision, partial mastectomy followed by radiation therapy or a type of mastectomy. With both options the primary aim is to remove the tumor burden to pathologically negative margins. For the axillary lymph node assessment an axillary sentinel lymph node (SLN) biopsy or an axillary lymph node dissection (ALND) needs to be performed for the invasive breast cancers.
Breast Conservation
Determining which is the optimal surgical intervention requires a thorough discussion with the patient taking into consideration a multitude of factors, in-cluding tumor size, tumor location, extent of disease, tumor characteristics, ability to receive adjuvant radiation therapy, and genetic predisposition. Breast cancer patients with multicentric disease, unable to receive radiation therapy or persistently positive surgical margins despite multiple excisions, will not be candidates for breast conservation and will require a mastectomy. There is a relative contraindication to breast conservation in patients with large tumors relative to the native breast size. Often times, if these patients are interested in breast conservation neoadjuvant chemotherapy or neo-endocrine therapy might be offered to reduce the tumor burden and make the patient a better operable candidate.
Contraindications to BCT:
Absolute—There are few absolute contraindications to BCT. In most of these cases, attempts to preserve the breast have been fraught with very high rates of in-breast recurrence:
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Persistently positive resection margins after reasonable reexcision attempts.
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Multicentric disease in which there are two or more primary tumors in separate breast quadrants.
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Diffuse malignant-appearing mammographic micro-calcifications, suggesting multicentricity.
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A history of prior radiation therapy (RT) to the breast or chest wall; this usually precludes further RT.
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Pregnancy, although it may be possible to perform breast-conserving surgery in the third trimester, deferring breast RT until after delivery.
Relative—Relative contraindications include the following:
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Patients with a history of scleroderma tolerate RT poorly and have a greater possibility of dermal complications. Whether other connective tissue diseases (e.g., rheumatoid arthritis, lupus) are associated with an increased risk of acute or late skin complications is controversial.
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Breast size is not in itself a contraindication to BCT. However, a large tumor in a small breast is a relative contraindication, as an adequate resection would result in significant cosmetic alteration.
Mastectomy
When a mastectomy needs to be performed or when it is the patient’s personal choice issues pertaining to breast reconstruction options, different types of mastectomy and management of the contralateral breast need to be addressed. Provided all clinical factors are equal and there is no contraindication to breast preservation, the overall survival for the breast cancer patients is the same. The main difference between breast conservation and mastectomy is the local recurrence. For breast conservation (lumpectomy followed by radiation) versus mastectomy, the local recurrence is 10% versus 2%–5%, respectively. Often times, the patients have unrealistic expectations, and these need to be clarified as part of the surgical planning.
Types of mastectomy include as follows:
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Total mastectomy . A total mastectomy, also known as a simple mastectomy, involves removal of the entire breast, including the breast tissue, areola, and nipple. A SLN biopsy may be done at the time of a total mastectomy.
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Skin-sparing mastectomy . A skin-sparing mastectomy involves removal of all the breast tissue, nipple, and areola but not the breast skin. A SLN biopsy also may be done. Breast reconstruction can be performed immediately after the mastectomy.
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Nipple-sparing mastectomy . A nipple- or areola-sparing mastectomy involves removal of only breast tissue, sparing the skin, nipple, and areola. A SLN biopsy also may be done. Breast reconstruction is performed immediately afterward.
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Modified radical mastectomy . A modified radical mastectomy involves removal of the entire breast, areola, and nipple with a complete ALND.
Breast Reconstruction
Breast reconstruction has increased in popularity, largely due to changing attitudes among women with breast cancer and their doctors, and recognition of the psychosocial benefits gained by reconstruction. The type of breast surgery impacts on the need for breast reconstruction.
Patients who require a mastectomy or those who choose to proceed with a mastectomy need to be referred for plastic surgery consultation to further explore the reconstructive options. The two main types of reconstruction include implant based versus autologous tissue reconstruction. Both types of procedures may be performed at the time of the primary breast cancer surgery or deferred. With immediate reconstruction the surgical process is streamlined, since both tumor resection and reconstruction are performed in one operative setting. There appears to be no adverse oncologic impact for immediate compared to delayed reconstruction. In addition, the emotional benefit of having begun reconstruction at the time of extirpation may reduce the impact of the loss of a breast. On the negative side, surgical time is lengthened with immediate reconstruction, and potential complications of mastectomy (e.g., skin loss and infection) or postoperative RT can adversely affect the reconstruction.
A myriad of factors impacts the decision of the optimal recommendation. There are different types of mastectomy that may be performed, including total mastectomy, skin-sparing mastectomy, and nipple- and areola-sparing mastectomy. Determining the optimal type of mastectomy depends on the location of the tumor, breast and tumor size, breast ptosis, and any previous breast surgical procedures. It is important to know that not all patients are equally eligible for the different options. Often times, the reconstruction occurs in multiple stages, and the reconstructive surgeon has to work with the rest of the multidisciplinary team especially when adjuvant chemotherapy or postmastectomy radiation therapy is required.
It is vitally important that the reconstructive surgeon be consulted before definitive breast cancer surgery takes place so that an in-depth discussion regarding options for reconstruction can be undertaken with the patient and her family.
Axillary Lymph Node Assessment
The status of the axillary nodes is the single most important prognostic factor in women with early-stage disease. Furthermore, axillary metastases are an important indicator of the need for adjuvant systemic therapy and postmastectomy RT.
Irrespective of the breast management, the axillary node assessment needs to occur for the invasive breast cancers. In patients with a clinically negative axilla at presentation, the state-of-the-art is to perform an axillary SLN biopsy. Depending on surgeon preference, there are three different techniques that may be used with the injection of isosulfan blue dye, sulfur colloid technetium 99, or a combination of both. By definition, the SLN biopsy will identify the first node that the breast cancer is draining to for staging purposes. In the event the axillary SLN has evidence of metastatic disease, then the need to proceed with a complete ALND will be discussed based on the pathological findings. If the patient presents with clinically palpable nodes, then further assessment with an axillary ultrasound and possible core biopsy might be recommended to exclude metastatic disease. If there is evidence of axillary biopsy-proven metastasis, neoadjuvant chemotherapy might be necessary to downstage the axilla and try to avoid an axillary dissection. In an attempt to avoid unnecessary morbidity associated with the axillary assessment, the Choosing Wisely campaign advocates to avoid axillary SLN biopsy in women 70 years of age or older with favorable tumor characteristics. If the axillary lymph node information is not going to change the overall management, why expose these patients to increased morbidity?
Description of How the Surgeries Are Performed
Lumpectomy
The lumpectomy procedure begins with locating the area of the breast that contains the abnormality. If the breast abnormality was detected on a mammogram or breast ultrasound and confirmed with a biopsy, the radiologist would have placed a marker or clip to allow for subsequent identification of the area. If this is the case, a thin wire, a reflector, or radioactive marker may be inserted just before surgery to identify the marker or clip. This allows the surgeon to use the wire/reflector or radioactive seed as a guide to the precise area that needs to be removed during surgery. In the case of a palpable mass that can be easily found, no localization will be necessary as the surgeon can easily find the abnormal area to be excised. The location of the lumpectomy scar depends the tumor location. All the breast tissue excised is sent for pathologic analysis. Key pathologic information will be the margin assessment as all margins need to be free of cancer in order to proceed with a successful lumpectomy. If there is evidence of residual carcinoma at any of the margins, then a breast reexcision or mastectomy will be necessary. The lumpectomy procedure is usually an outpatient surgery procedure and may be performed under monitored anesthesia care or general anesthesia depending on the surgeon’s preference and the patient’s comorbidities.
Mastectomy
A mastectomy is usually performed under general anesthesia. The breast tissue is removed, and depending on the procedure, other parts of the breast also may be removed, including the nipple and the areola. If an immediate breast reconstruction is planned, the breast surgeon will coordinate with the plastic surgeon to plan the surgery and the incisions. The mastectomy is an anatomic operation that requires removal of the breast tissue from the clavicle as the superior margin, the lateral border of the sternum medially, the inframammary fold inferiorly, the latissimus dorsi muscle laterally, and the pectoralis major muscle posteriorly. All these anatomic landmarks need to be identified to assure proper breast tissue removed. There needs to be close attention to the mastectomy flaps not to compromise the vascular supply. Issues pertaining to the preservation of the nipple–areolar complex are an important part of the discussion and presurgical planning. If the patient is deemed to be a candidate for preservation of the nipple–areolar complex, the nipple tissue needs to be sent for intraoperative frozen section analysis to assure that it is safe from the oncological standpoint. As the surgery is completed, the incision is closed with stitches (sutures) that either dissolve or are removed later. Given the size of the mastectomy wound, surgical drains are left in place and removed in the postoperative period.
One option for breast reconstruction involves placing temporary tissue expanders in the chest. These temporary expanders will form the new breast mound. For women who will have radiation therapy after surgery, one option is to place temporary tissue expanders in the chest to hold the breast skin in place. This allows you to delay final breast reconstruction until after radiation therapy.
Lymph Node Surgery
Lymph nodes are often removed during surgery to determine whether cancer has spread beyond the breast. Options may include the following:
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Axillary node dissection . It is usually reserved for patients with known axillary metastasis. This requires general anesthesia with anatomic removal of axillary nodes levels I and II that are lateral and deep to the pectoralis minor muscle. Intraoperatively will require identification of the long thoracic and thoracodorsal nerves, axillary artery, and vein and if possible preservation of the costobrachial sensory nerves. Patients will require a surgical drainage to avoid a postoperative fluid collection. Ideally, these patients should be evaluated preoperatively by the rehabilita-tion oncology service to have a baseline assessment prior to surgical intervention.
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SLN biopsy . The surgeon removes only the first one or two nodes into which a tumor drains (sentinel nodes). These are then tested for cancer. Before the surgery a radioactive substance or blue dye or both is injected into the area around the tumor or the skin above the tumor. The dye travels to the sentinel node or nodes, allowing the surgeon to identify which are the nodes that need to be removed. All the sentinel nodes removed are submitted for pathologic analysis. If the final pathology shows no evidence of cancer, no further lymph nodes need to be removed. If cancer is present, the surgeon will discuss options, such as receiving radiation to the axilla to treat the affected lymph node versus a complete ALND for local control and staging purposes.
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Postoperative management . Postoperatively, further recommendations will be dependent upon the final pathologic findings. Provided the surgical margins are negative for cancer and no further axillary surgery is necessary, the patients are then referred to the medical and radiation oncology services as needed for further evaluation and management to maximize the breast cancer cure.
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For those patients who underwent an immediate breast reconstruction coordination of care, the rest of the multidisciplinary team is very important.
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For patients with an ALND, follow-up with the rehabilitation service is critical for upper extremity lymphedema prevention.
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Common postsurgery complications . Most breast operations are categorized as low-morbidity procedures, but a variety of complications can occur in association with diagnostic and multidisciplinary management procedures. Some of these complications are related to the breast itself, and others are associated with axillary staging procedures.
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General wound complications related to breast and axillary surgery such as infection, bleeding/hematoma, seroma, paresthesias, sensory loss, tingling, and keloid formation.
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Complications specific to lumpectomy procedures such as breast asymmetry, breast deformity, inability to lactate (central location), and compromised nipple sensation.
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Complications specific to mastectomy procedures such as breast asymmetry, flap necrosis, phantom pain, reconstruction-related capsular contractures, reduced upper extremity range of motion, and right upper extremity limited range of motion.
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Complications related to axillary staging procedures
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Although major complications of ALND are infrequent (e.g., injury or thrombosis of the axillary vein, injury to the motor nerves, and severe lymphedema), minor complications are much more common (e.g., seroma formation, shoulder dysfunction, loss of sensation in the distribution of the intercostobrachial nerve, and mild edema of the arm and breast). Arm edema is more common in women who undergo more extensive ALND, especially when combined with postoperative RT to the axilla. SLN biopsy is associated with a significant reduction in arm morbidity compared to ALND.
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Axillary web syndrome (AWS) . AWS is a common condition occurring in up to 86% of patients following breast cancer surgery with ipsilateral lymphadenectomy of one or more nodes. AWS presents as a single cord or multiple thin cords in the subcutaneous tissues of the ipsilateral axilla. The cords may extend variable distances “down” the ipsilateral arm and/or chest wall. The cords frequently result in painful shoulder abduction and limited shoulder range of motion. AWS most frequently becomes symptomatic between 2 and 8 weeks postoperatively but can also develop and recur months to years after surgery. Education about and increased awareness of AWS should be promoted for patients and caregivers. Physical therapy, which consists of manual therapy, exercise, education, and other rehabilitation modalities to improve range of motion and decrease pain, is recommended in the treatment of AWS.
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Lymphedema . Lymphedema can develop in the breast cancer patient as a result of the interruption of lymphatic flow from postsurgical, postradiation, taxane-based chemotherapy, and infectious causes. It can present at various points after breast cancer treatment and may range from mild to a seriously disabling enlargement. Because lymphedema is permanent, the goal of treatment options is the control of edema, and a multidimensional approach to care is often needed. Early detection and intervention, including preoperative consultation in those patients undergoing an ALND, is paramount to decrease the likelihood of this morbidity.
Implications of Rehabilitation
Given that breast cancer patients are surviving their breast cancer, quality of life issues and maintenance of functional performance status have become very important. As such, prerehabilitation and postoperative rehabilitation are critical components of the multidisciplinary approach to breast cancer. Key areas to be addressed include
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lymphedema prevention and treatment,
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AWS, and
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shoulder.
Patient Education
As the options for the multidisciplinary approach to breast cancer treatment are so complex and diverse, the patients and their family members need to be well informed and educated about the different treatment options with the associated side effects, expected recurrence and breast cancer survival rates. It is not only important to educate the patients on their treatment options but also to have realistic expectations about the quality of life issues and potential side effects on their physical performance and mental health.
Areas of Future Research
One of the most challenging sequelae of the breast cancer treatment is the management of breast cancer–related lymphedema.
In 2017 the American Society of Breast Surgeons convened an international multidisciplinary consensus panel to discuss this important topic, and the manuscripts describe the recommendations from this panel and shed some light on the prevention, diagnosis, and new treatment strategies for this potentially debilitating condition. There is ongoing research to stratify the risk of lymphedema and identify patients who might benefit from techniques, such as axillary reverse mapping (ARM) and/or lymphatic microsurgical preventative healing approach (LYMPHA). ARM entails mapping upper extremity lymphatics with blue dye allowing for differentiation of lymphatics draining the breast (radioactive) and the upper extremity (blue). In the only prospective study, Yue et al. randomized 265 patients to undergo ALND versus ALND+ARM. With 20-month follow-up, lymphedema developed in 33% of patients in the ALND group and 6% of the ALND+ARM group.
LYMPHA is a surgical approach for the primary prevention of arm lymphedema following axillary nodal dissection. The idea of LYMPHA was conceived 10 years ago, and the preliminary results were published a few years after. LYMPHA couples lymphovenous bypass with ALND performing an anastomosis dunking the transected main lymphatic trunk(s) into a lateral branch of the axillary vein distal to a competent valve. Furthermore, which patients with lymphedema refractory to physical therapy and compression garments would benefit from lymph node transfer surgery? With improved understanding of the underlying pathophysiology of lymphedema, newer strategies both in the prevention and treatment of lymphedema continue to emerge. Also, we need to acknowledge that lymphedema may be secondary to factors other than just axillary surgery, including radiation therapy and chemotherapy, especially taxanes-based chemotherapy.
SLN surgery has been the standard of care for axillary staging of the clinically negative axilla since the late 1990s. It has decreased the likelihood of upper extremity lymphedema associated with axillary surgery from 20%–40% to 5%–7%. One could argue that for a staging procedure, albeit lower, this is still a significant risk. Hence, can we identify subsets of patients where axillary surgical staging can be avoided altogether? The recent Society of Surgical Oncology Choosing Wisely guidelines recommended against SLN surgery in women older than age 70 years with hormone receptor-positive breast cancer. There is a model to predict likelihood of nodal positivity that can be useful for patients and surgeons to identify those women age 70+ at low risk of nodal positivity where SLN surgery may be avoided, and also to identify those women at higher risk of nodal positivity where surgical staging of the axilla may alter treatment recommendations.
Another ongoing, controversial debate in breast cancer is the appropriate treatment for ductal carcinoma in situ (DCIS). Currently, there are three randomized, controlled trials for low-risk DCIS underway in Europe and the United States designed to test the safety, efficacy, and trade-offs of active surveillance compared with usual care: LORIS (multicenter UK study), LORD (EORTC study), and COMET (comparison of operative to monitoring and endocrine therapy trial for low-risk DCIS—a cooperative group US study). All three trials seek to identify a subset of patients with DCIS with low risk of both occult invasive disease at initial presentation and subsequent progression to invasive disease.
Conclusion
The field of breast cancer is extremely dynamic. Research, technology, and better understanding of biology continue to drive the needle forward to cure breast cancer with the ultimate goal to one day prevent and eliminate breast cancer. In the meantime, it is with a tailored individualized multidisciplinary approach to breast cancer treatment that we will continue to optimize the oncologic outcome with good quality of life.
Patient Resources
American Cancer Society Breast Cancer Facts and Figures
NCI breast cancer Website
References
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