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Mastectomy versus breast conserving surgery (BCS)
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Breast Cancer (BC) is considered the most implacable malignancy and the leading cause of mortality in the Kingdom of Saudi Arabia (KSA). The literature on different aspects of BC is rich in contributions from developed and Western countries. Nevertheless, despite substantial individual efforts, the views of experts from KSA lack a collective portrayal. Hence, an attempt has been made to gather together the information in the form of an overview which includes some facets of BC. The views of experts from Saudi Arabia on these aspects of BC in the Kingdom included an amalgamation of a variety of articles published during last more than thirty years from different research and teaching institutions. The task was met up with peer reviewed english language articles cited in Pub Med, Pub Med Central, Science Direct, Up-to-date, Med Line, Comprehensive data bases, Cochrane library and the internet (Google, Yahoo). The study provides impetus on further analysis of the association between epidemiology, knowledge of BC and practice of breast self-examination (BSE), etiological factors, metastases and rate of survival. Further studies are warranted to enrich the information for planning of screening, management and preventive strategies of BC in KSA, which may indirectly benefit worldwide health care.
About 57% of the total number of cancer cases occur in low and middle income countries. Radiotherapy is one of the main components of cancer treatment and requires substantial initial investment in infrastructure and training. Many departments continue to have basic facilities and to use simple techniques, while modern technologies have only been installed in big cities in upper-middle income countries. More than 50% of cancer patients requiring radiotherapy in low and middle income countries lack access to treatment. The situation is dramatic in low income countries, where the proportion is higher than 90%. The overall number of additional teletherapy units needed corresponds to about twice the installed capacity in Europe. The figures for different income level groups clearly show the correlation between gross national income per capita and the availability of services. The range of radiotherapy needs currently covered varies from 0% and 3–4% in low income countries in Latin America and Africa up to 59–79% in upper-middle income countries in Europe and Central Asia. The number of additional radiation oncologists, medical physicist, dosimetrists and radiation therapists (RTTs) required to operate additional radiotherapy departments needed is 43 200 professionals. Training and education programmes are not available in every developing country and in many cases the only option is sending trainees abroad, which is not a cost-effective solution. The implementation of adequate local training should be the following step after establishing the first radiotherapy facility in any country. Joint efforts should be made to establish at least one radiotherapy facility in countries where they do not exist, in order to create radiotherapy communities that could be the base for future expansion.
Breast cancer is the most common female cancer in Western populations, affecting 12.5% of women, with 1.38 million patients per year. Breast-conserving surgery followed by postoperative radiotherapy replaced the radical and modified-radical procedures of Halsted and Patey as the standard of care for early-stage breast cancer once the overall and disease-free survival rates of breast-conserving surgery were demonstrated to be equivalent to those of mastectomy. However, excision of >20% of breast tissue, low or centrally located cancer, and large-sized breasts with various grades of breast ptosis, result a in unacceptable cosmetic outcomes. Oncoplastic breast surgery evolved from the breast-conserving surgery by broadening its general indication to achieve wider excision margins without compromising on the cosmetic outcomes. Thus, oncoplastic breast surgery can be defined as a tumor-specific immediate breast reconstruction method that applies aesthetically derived breast reduction techniques to the field of breast cancer surgery and allows for higher volume excision with no aesthetic compromise. However, contralateral breast symmetrization should be regarded as an intrinsic component of the oncoplastic surgery. The main procedures involved are volume-displacement or volume-replacement techniques, which depend on breast size and cancer size/location. Volume-displacement or reshaping procedures apply the plastic surgery principles to transpose a dermo-glandular flap of breast tissue into the defect site, while volume-replacement techniques use autologous tissues to replace the volume loss that follows tumor resection. Furthermore, these procedures are more complex and time-consuming than those involved in breast-conserving surgery. Based on current literature, the authors analyze the different techniques and indications of the oncoplastic breast surgery, determining its complication rate, in order to help both surgeons and their patients in the decision-making stage of breast reconstruction.
Breast cancer staging concisely summarizes disease status, creating a framework for assessing and relaying prognostic information. The fundamental concepts and components of breast cancer staging are reviewed. The AJCC Cancer Staging Manual, which includes traditional anatomic factors, now includes additional tumor characteristics: tumor grade, estrogen receptor status, progesterone receptor status, human epidermal growth factor receptor 2 status, and (when available) multigene panel testing from the primary tumor. With these updates, staging provides the most reliable system for accurately predicting patient outcome. When the AJCC 8th edition guidelines are adopted, they will more closely reflect tumor biology.
In the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer, among adjuvant radiotherapy options for whole-breast irradiation after breast-conserving surgery, hypofractionation is preferred. For the use of accelerated partial-breast irradiation, the NCCN Guidelines have adopted the updated definition of “suitability” used by the American Society for Radiation Oncology. Regional nodal irradiation is indicated—either in the setting of breast-conserving surgery or after mastectomy—for women with ≥4 positive nodes and should be strongly considered for 1 to 3 positive lymph nodes and select patients with node-negative disease deemed at high risk for recurrence.
Breast-conserving therapy is one of the most remarkable achievements of modern cancer care. The authors review the evidence supporting the role of adjuvant radiotherapy as the standard of care for breast cancer after breast-conserving surgery, consensus guidelines for margins in invasive cancer disease and ductal carcinoma in situ, the role of partial-breast irradiation and hypofractionated whole-breast irradiation, and the evolving indications for postmastectomy radiation therapy and extent of nodal coverage. Areas of research include specific methods of partial-breast irradiation, interactions between neoadjuvant chemotherapy and radiotherapy, and integration of molecular profiles with the selection of the best treatment modality and timing.
Background:
Multiple randomised trials and meta-analyses have supported the use of conservative surgery (CS) and radiation therapy (RT) for the treatment of early-stage breast cancer. Following lumpectomy, RT has been shown to decrease the chance of local recurrence and improve overall survival when compared with lumpectomy alone.
Objective:
This update outlines the rationale and outcomes for CS and RT, whether a subgroup exists in which RT may be safely omitted, the process of RT, common side effects and their management, and the latest techniques in the field.
Discussion:
Breast conservation remains an effective treatment for breast cancer without a survival disadvantage to a mastectomy. The combination of advanced imaging and fast three-dimensional (3D) radiotherapy planning computer systems have allowed new techniques that deliver RT more accurately, with better tumour control, fewer side effects and improved survival.
Radiotherapy has had a transformative impact on the treatment of breast cancer, but is unavailable to the majority of breast cancer patients in low- and middle-income countries. In these settings, where many women present with advanced disease at an age when they are often the primary caregiver for their families, the lack of access to radiotherapy is particularly devastating. Until recently, this disparity has been largely neglected in the medical literature and it had been difficult to convince governments, industry, and policymakers of the importance of investing in radiotherapy, as well as broader cancer control strategies, in low-resource settings. The Lancet Radiotherapy Commission report published in 2015 challenged many assumptions about the affordability of radiotherapy treatment. Data from the Commission is presented here to support radiotherapy investment for breast cancer and discuss how the morbidity and premature mortality among adult women caused by breast cancer has a huge detrimental effect on both the health sector and the economy.
Background
Tamoxifen and raloxifene reduce the risk of breast cancer in women at elevated risk of disease, but the duration of the effect is unknown. We assessed the effectiveness of selective oestrogen receptor modulators (SERMs) on breast cancer incidence.
Methods
We did a meta-analysis with individual participant data from nine prevention trials comparing four selective oestrogen receptor modulators (SERMs; tamoxifen, raloxifene, arzoxifene, and lasofoxifene) with placebo, or in one study with tamoxifen. Our primary endpoint was incidence of all breast cancer (including ductal carcinoma in situ) during a 10 year follow-up period. Analysis was by intention to treat.
Results
We analysed data for 83 399 women with 306 617 women-years of follow-up. Median follow-up was 65 months (IQR 54–93). Overall, we noted a 38% reduction (hazard ratio [HR] 0·62, 95% CI 0·56–0·69) in breast cancer incidence, and 42 women would need to be treated to prevent one breast cancer event in the first 10 years of follow-up. The reduction was larger in the first 5 years of follow-up than in years 5–10 (42%, HR 0·58, 0·51–0·66; p<0·0001 vs 25%, 0·75, 0·61–0·93; p=0·007), but we noted no heterogeneity between time periods. Thromboembolic events were significantly increased with all SERMs (odds ratio 1·73, 95% CI 1·47–2·05; p<0·0001). We recorded a significant reduction of 34% in vertebral fractures (0·66, 0·59–0·73), but only a small effect for non-vertebral fractures (0·93, 0·87–0·99).
Interpretation
For all SERMs, incidence of invasive oestrogen (ER)-positive breast cancer was reduced both during treatment and for at least 5 years after completion. Similar to other preventive interventions, careful consideration of risks and benefits is needed to identify women who are most likely to benefit from these drugs.
Funding
Cancer Research UK.
The rage for breast surgery attained manic proportions in the late 19th century in the United States and Europe. But the trend was driven by surgeons, not women, and the results were far from aesthetic.⇑
Surgeons in ancient Egypt described breast cancer, but wisely refrained from wielding the knife. The first recorded attempt at mastectomy is attributed to the surgeon Leonides of Alexandria in about the second century AD, but caution remained the watchword. By the 1600s prints in northern Europe show women stoically undergoing breast amputations by surgeons using forceps, knives, and cauterising irons long before the arrival of anaesthesia or antisepsis.
In 1748 the German surgeon Lorenz Heister described using a fork, or ropes attached …
Randomized trials have shown improved local control with the use of a breast boost for patients given breast-conserving treatment for breast carcinoma. Although the use of a breast boost is routine practice, no standard technique has been established. The authors compared the commonly used clinical technique with a technique based on computed tomography (CT) imaging of surgical clips in the tumor bed.
Thirty patients underwent CT simulation for postoperative radiation treatment planning as part of breast conservation therapy. During simulation, a CT-compatible wire was placed on the patient's skin, outlining the intended electron boost field; an electron boost volume (EBV) was generated by contouring the tissue underlying the wire. Also contoured was a CT-based clinical target volume (CTV) using surgical clips and postsurgical changes in the tumor bed as a guide. A planning target volume (PTV) was generated using a 1 cm margin around the CTV. An electron beam treatment plan was generated for each technique using the FOCUS three-dimensional treatment planning system. Dose-volume histograms (DVH) were generated to determine the fraction of the PTV receiving 90% of the prescribed dose if treatment was delivered using the EBV. In addition, DVH analysis was done to determine the volume of normal tissue unnecessarily irradiated when using the EBV.
Although the electron cone size remained unchanged in most patients for both EBV and PTV, the isocenter differed more than 1 cm in the medial-lateral direction in 5 patients and in the cephalocaudal direction in 12 patients. The en face gantry angle differed for most patients. On average, only 51% (range, 27-79%) of the PTV received 90% or more of the prescribed dose when the electron plan was generated using the EBV (P < 0.0001). Ten patients received the prescription dose to less than 50% of the PTV. Mean volume of normal tissue receiving more than 50% of prescribed dose was 64.5 cm(3) (range, 24-119 cm(3)).
Clinical delineation of the tumor bed not only carries a significant risk of missing the target, but unnecessarily treats breast tissue that may otherwise be spared. Better delineation of the tumor bed, which optimizes coverage of the target volume and spares normal breast tissue, has the potential to improve both local control and cosmetic outcome. The authors recommend the use of surgical clips to delineate the target volume, followed by CT-based treatment planning, accounting for not only microscopic disease, but also organ motion and daily setup error.
Registries and research on breast cancer in Arabic and developing countries are limited.
We searched PubMed, Medline, WHO and IAEA publications, national, regional, hospital tumor registries and abstracts. We reviewed and analyzed available data on epidemiological trends and management of breast cancer in Arab countries, and compared it to current international standards of early detection, surgery and radiation therapy.
Breast cancer constitutes 13-35% of all female cancers. Almost half of patients are below 50 and median age is 49-52 years as compared to 63 in industrialized nations. A recent rise of Age-Standardized Incidence Rates (ASR) is noted. Advanced disease remains very common in Egypt, Tunisia, Saudi Arabia, Syria, Palestinians and others. Mastectomy is still performed in more than 80% of women with breast cancer. There are only 84 radiation therapy centers, 256 radiation oncologists and 473 radiation technologists in all Arab countries, as compared with 1875, 3068 and 5155, respectively, in the USA, which has an equivalent population of about 300 million. Population-based screening is rarely practiced. Results from recent campaigns and studies show a positive impact of clinical breast examination leading to more early diagnosis and breast-conserving surgery.
Breast cancer is the most common cancer among women in Arab countries with a young age of around 50 years at presentation. Locally advanced disease is very common and total mastectomy is the most commonly performed surgery. Awareness campaigns and value of clinical breast examination were validated in the Cairo Breast Cancer Screening Trial. More radiation centers and early detection would optimize care and reduce the currently high rate of total mastectomies. Population-based screening in those countries with affluent resources and accessible care should be implemented.