Pitfalls and Problems In the Management of Early Breast Cancer

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Pitfalls and Problems In the Management of Early
Breast Cancer

• Caroline Baker
• Austin Health
• Mercy Private and Warringal Hospitals

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Times Have Changed.

• Breast cancer is high profile media
  internet social networks consumer activism
• Patients are more educated and aware
• Patients are more demanding

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Pre Diagnosis

• High level of anxiety encourage a companion
  from beginning clear and friendly
  introduction acknowledge anxiety will be
  there write everything down explain
  salient points at least twice emphasise area
  of expertise

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Pitfalls The Wrong Operation

• 1/ inaccurate assessment of disease extent at
  time of presentation careful clinical review
  inspection whilst upright
  for skin changes caliper
  measurement
• impact of prior biopsy
• cynical review of imaging especially US
  

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Pitfalls The Wrong Operation

• 2/ inadequate time for patient contemplation
  breast size and shape acccess to, and demands
  of , radiotherapy underlying
  psychological state input from plastic
  surgeons choosing because of perceived impact
  of delay for combined operation
• role of family history events death of
  relative when young genetics

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The Role of Family History

• Take an accurate one, corroborate if
  possible Sallys story1st consultation alone
  pat Gm ca breast 60s,mat aunt 50s
• 2nd consultation with both parents father only
  child, pat GM bilateral 50 and 75, her only 2
  sisters 40s and 60s, only female offspring ca
  45..

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The Role of Family History

• Remember prognosis is determined by that of
  first cancer and not that of possible second
  cancer versus
• I cant go through this all again.
• Rapid genetic analysis access chance for
  discussion of BRCA mechanism of
  action and inheritance impact on choice of
  operation???? Try and clarify this Ellys
  story

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Pitfalls The Wrong Operation

• 3/ inadequate respect for pathology truisms
  lobular lobular lobular . . . . Remember
  imaging occult and bilateral
• care when discussing immediate reconstruction
  with ILC . . . . delay in chemotherapy if
  subsequent infection un expected need
  for radiotherapy

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Pitfalls The Wrong Operation

• 4/ concordance of the triple test
• clinical imaging pathology

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Pitfalls The Wrong Operation

• 5/ Challenging patients breast
  implants previous breast reduction mammographica
  lly dense breasts gigantomastia pregnancy and
  lactation previous cancer treatment

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Pitfalls The Wrong Operation

• 6/ Sentinel Node Biopsy vs Ax
  Clearance prior indications T lt 3
  cm unifocal disease N0 clinically and on
  US not inflammatory or neoadjuvant These are
  all being reviewed . . .

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Pitfalls The Wrong Operation

• 6/ Sentinel Node Biopsy vs Ax
  Clearance 6th International SNB Meeting Feb
  2008 only C/I is a positive node on biopsy
  work out a likely risk of node positivity
  based on known parameters from the core biopsy
  and let pt choserisk of reoperation vs risk of
  arm effectsneed for a full AxC even if SNB
  ????

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What is Sentinel Node Positive Anyway?

• Risk of Subsequent AxC (Viale,2007)ITC 10
  Micromet 14Macromet 21
• Jans story

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How Can We Get it Right More Often? Is Breast MRI
the White Knight?ACR Indications for Breast MRI
(2006)

• Lesion characterization where inconclusive/difficu
  lt with mammo and US and mismatch with clinical
  findings
• Evaluation of ILC
• Axillary lymphadenopathy with unknown primary
• Evaluation after WLE with close/ margins

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ACR Indications for Breast MRI (2006) continued

• ?recurrence following reconstruction/BCT
• Response to neoadjuvant chemotherapy
• Assessment of implant integrity
• Surveillance of high risk women
• Implant rupture

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Why Not Do an MRI?

• costly and unrebated
• claustrophobic, noisy and undignified
• no tissue diagnosis
• repeat US / MRI generated
• steep learning curve
• ?improved survival
• consumer pressure !

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Surveillance of High Risk Women

• Kriege et al 2004

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Surveillance of High risk Women

• MARIBS study group,2005

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MRI for Diagnosing Pure DCIS C.Kuhl et al

• Unselected 7319 women imaged over 5 years. 1208
  abnormal imaging ? 572 B9 results 469 inv
  BC 167 DCIS
• 93/167 mammo visible 56153/167 MRI detected
  92
• Grade mammo best at low grade, only 35 of high
  grade seen

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MRI for DCIS

• MRI highest sensitivity in high grade
  (98),which detected periductal vascular cuffing
• No correlation between breast density and
  invisibility on mammo/MRI !!
• Size 28.4mm(mammo only) vs 26.6 mm (MRI only)

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MRI Posters San Antonio Dec 2007

• MRI impact on management preopNewstead et al Uni
  of Chicago
• 459 cases extra cancer 23.1 larger
  lumpectomy 19.1 mastectomy 2.8 neoadjuvant
  rx 1 contralateral ca 4.5
• Schell et al Dartmouth 211 pts 15 ipsilat ca ,
  4 c/l ca
• 12 change to management

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MRI CONTRAINDICATIONS

• PACEMAKER
• ANEURYSM CLIPS
• NEUROSTIMULATOR
• METAL FB EYE
• COCHLEAR IMPLANT
• TISSUE EXPANDER WITH PORT
• ? PREGNANCY

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BREAST MRI INTERPRETATION

• MORPHOLOGY
• CONTRAST ENHANCEMENT

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BREAST MRI INTERPRETATION

• MALIGNANT
• IRREGULAR SHAPE
• SPICULATED MARGIN
• SEGMENTAL or peripheral ENHANCEMENT
• CLUMPED, LINEAR, DUCTAL
• WASHOUT KINETICS 57

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BREAST MRI INTERPRETATION

• BENIGN
• SMOOTH MARGIN
• NON ENHANCING SEPTAE
• MULTIPLE 2-5mm foci OF ENHANCEMENT
• PLATEAU OR PROGRESSIVE ENHANCEMENT 83

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BILATERAL BREAST CANCER
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BILATERAL BREAST CANCER
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MULTICENTRIC TUMOUR
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MULTICENTRIC TUMOUR
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Pitfalls Communication Difficulties

• Language and cultural differences Toulas
  story
• Overestimating what is understood laymens
  language breast care nurse repetition written
  record My Journey Kit GP involvement
• And still . . . . Hilarys story

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Pitfalls Communication Difficulties

• dont blame pt for this. . . Deep breathe !!
• tag team mentality
• encourage pt to relate the story back to you
• keep a copy of written record given to
  ptBarbs story
• bring record of previous consult with them

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Pitfalls Communication Difficulties

• The Well Meaning Husband/Friend control of the
  consultation my pt needs to understand
• too much information preempt this or
  big trouble. . . as much or as little as my
  pt wants to know, including figures
• when I had My cancer treatment blah,
  blah, blah !!Brian and Norahs story All
  cancers are different, and modern cancer
  treatment is individualised

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Pitfalls Communication Difficulties

• The Pear Shaped Consultationrunning
  lateno/forgotten /lost referral and filmssecond
  opinioninterruptions/phone callsdelay in
  diagnosis or getting an appointmentaggressive/ang
  ry language from the beginning
• talk under water

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Pitfalls Communication Difficulties

• The Pear Shaped ConsultationApologise for
  lateness/interruptions
• Be polite, solicitious , reassuring but firmLet
  conversation flow for a couple of minutes
  ofventing, then take the lead
• I dont need to know that today
• What questions would you like to ask?
• Your GP would like to know that
• Would you like a second opinion?

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Summary

• After 10 years it is still a challenge to get it
  right for each pt
• Time spent getting it right is well spent so
  try and avoid the operation yesterday approach
• The team approach is best for all !!

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