Over 1,300 breast surgeons attended the 13th Annual Meeting of the American Society of Breast Surgeons, held May 2–6 in Phoenix. Presentations included investigations on recurrence after lumpectomy, gender differences in breast cancer, and the potential role of infrared thermography in diagnosing the disease.
Lumpectomy for High-risk Locally Advanced Breast Cancer
High-risk breast tumors that respond well to neoadjuvant chemotherapy can be safely treated with lumpectomy, according to University of California, San Francisco, researchers, who determined that tumor biology dictates recurrence in this group, and that local recurrence was low regardless of surgical procedure.1
“Traditionally, there has been reluctance to use breast conservation for women with locally advanced cancers, especially in women with significant tumor remaining after presurgical chemotherapy,” said lead author Elizabeth Cureton, MD. “We wanted to evaluate the local recurrence rates from the I-SPY TRIAL, a multicenter neoadjuvant study, because we know that patients and physicians are often afraid to use breast-conserving surgery, because they believe that more surgery will be better for an aggressive tumor,” she said.
“But this was not the case,” she reported. “The I-SPY TRIAL has shown that tumor characteristics such as gene expression, advanced stage, and poor response to neoadjuvant therapy itself were the major predictors of cancer recurrence, and more surgery is not, therefore, necessarily better.”
The report, part of the I-SPY 1 trial, examined 206 patients, 90% of whom were classified as high-risk on the basis of the 70-gene expression profile. After neoajduvant chemotherapy, 90 women underwent lumpectomy (78 with radiation) and 116 had mastectomy (92 with radiation). In the overall group, after 3.9 years median follow-up, 45 (22%) had distant recurrences and 14 (7%) had local recurrences. Of the distant recurrence group, 10 also had local recurrences; only 4 of the 10 with local recurrences had no distant recurrences during the study.
Tumor size and lymph node status at diagnosis and at the time of surgery were significantly associated with recurrence. Women with poor response to neoadjuvant chemotherapy were also more likely to have recurrent disease.
By treatment type, local recurrence rates were low in both the lumpectomy group as well as the mastectomy group. These data were also no different in the setting of an excellent response to neoadjuvant chemotherapy or in the setting of residual disease.
Five-year local/distant recurrence-free survival was 79% with breast-conserving surgery and 72% with mastectomy. Surgical treatment was not randomized, and more patients with extensive disease were treated with mastectomy. Importantly, with multimodal therapy, local recurrence was not a significant problem.
Co-investigator Laura Esserman, MD, Co-leader of the Breast Oncology Program at UCSF Helen Diller Family Comprehensive Cancer Center, emphasized that distant metastatic disease, not local recurrence, is the major risk for this patient population.
She noted that the I-SPY 1 data have shown that excellent tumor response to neoadjuvant chemotherapy is a strong predictor that the disease will not recur locally. “Therefore, women who respond well to presurgical chemotherapy may not require other aggressive local treatment and may do well with lumpectomy instead of mastectomy,” she said.
Dr. Cureton added that if radiation is indicated, lumpectomy should be attempted as it carries less risk for complications than when paired with mastectomy.
Male Breast Cancer Is More Fatal
An analysis of male breast cancers from the National Cancer Data Base (NCDB) found that men have a significantly lower breast cancer survival rate than women, particularly for early-stage disease.2 This is the largest study ever conducted on gender differences in breast cancer.
The study compared 13,457 male and 1,439,866 female breast cancer cases entered from 1998 to 2007 in the NCDB. The study found that 5-year survival rates were 83% for women compared to 74% for men (P < .0001), reported Jon Greif, DO, FACS, of the Carol Ann Read Breast Health Center at Alta Bates Summit Medical Center in Oakland, California. The differences were most pronounced for early-stage disease (0, I, and II). There was little difference in survival for stages III and IV. Men presented with significantly larger tumors (median, 20 vs 15 mm), more frequent lymph node involvement (42% vs 33%), and more distant metastases (4% vs 3%). Differences in survival, in tumor size, and in regional and systemic involvement may be attributed to a lack of awareness of breast cancer in men and therefore delay in diagnosis.
Among male breast cancers, 88.3% were estrogen receptor–positive, yet only 41% of men were recorded as having been offered or taken hormonal therapy. “If these numbers are accurate, more liberal use of estrogen-blocking medication such as tamoxifen might improve outcomes,” Dr. Greif suggested.
Infrared Thermography Not a Useful Breast Cancer Screening Tool
Infrared thermography, a non–radiation-based imaging modality that measures thermal abnormalities in breast tissue, is not a reliable breast cancer screening tool, according to a study conducted at the Comprehensive Breast Cancer at Bryn Mawr Hospital, Bryn Mawr, Pennsylvania.3
The study examined 178 women with abnormal results on mammography, ultrasound, or magnetic resonance imaging (MRI) who underwent minimally invasive breast biopsy. The affected breasts were scanned using the No Touch Breast Scan (NTBS) system prior to biopsy, and the results were compared with pathology findings.
“The NTBS high-specificity mode missed 50% of all cancers, while the high-sensitivity mode delivered an unacceptable number of false-positives,” reported Cara Marie Guilfoyle, MD.
Initially, patients were evaluated using a high-specificity computerized analysis setting, which attempts to minimize the number of false-positive cancer results. Because this modality failed to detect many patients with positive pathology findings, the researchers switched to the high-sensitivity mode to optimize cancer detection from that point on. Scans from the early part of the study were reanalyzed using the high-sensitivity mode and both sets of results were reported.
In the high-specificity mode, 52 patients were found to have cancer, and infrared imaging failed to detect 26 cases (sensitivity 50%). Of 132 negative biopsies, 42 had positive findings on infrared (specificity 67%). The positive predictive value of infrared thermography was only 37%, and negative predictive value was 77%.
In the high-sensitivity mode, infrared thermography correctly identified 44 of the 46 positive breast biopsies (sensitivity 87%). Of the 116 negative biopsies, 61 were incorrectly identified as positive (specificity 48%). The positive predictive value of infrared thermography was 40%, and the negative predictive value was 90%.
Lead researcher Andrea Barrio, MD, commented, “These findings fail to point out a useful role for infrared thermography in our patient population and, therefore, show that infrared thermography cannot be used as a successful adjunct to mammography. For screening, mammography remains the gold standard.” ■
Disclosure: Drs. Cureton, Esserman, Greif, Guilfoyle, and Barrio reported no potential conflicts of interest.
References
1. Cureton E, Alvarado MD, Yau C, et al: Biology, not choice of mastectomy versus lumpectomy, dictates recurrence in high-risk breast cancer. 2012 American Society of Breast Surgeons. Abstract 260. Presented May 4, 2012.
2. Greif J, Pezzi C, Klimberg S, et al: Gender differences in breast cancer: Analysis of 13,000 male breast cancers from the National Cancer Data Base. 2012 American Society of Breast Surgeons. Abstract 104. Presented May 4, 2012.
3. Guilfoyle CM, Collett AE, Christoudias MK, et al: Does infrared thermography predict the presence of malignancy in patients with suspicious radiologic breast abnormalities? 2012 American Society of Breast Surgeons. Abstract 92. Presented May 4, 2012.
