Finding

On Cancer: New Breast Surgery Guidelines Aim to Spare Women Unnecessary Operations

By Media Staff  |  Monday, February 10, 2014
New guidelines recommend against surgery to remove additional normal tissue in women who’ve already had a lumpectomy. New guidelines recommend against surgery to remove additional normal tissue in women who’ve already had a lumpectomy.

Between 70 and 90 percent of women with newly diagnosed, early-stage breast cancer are candidates for breast-conserving surgery, or lumpectomy, followed by radiation. In this procedure, surgeons remove the cancer along with a small amount of normal tissue surrounding the tumor — known as a surgical margin — to reduce the chance of leaving cancer cells behind.

Roughly 25 percent of women who receive a lumpectomy return to the operating room to have additional normal tissue removed. Of these women, approximately half have negative margins — defined as no tumor cells at the edge of the lumpectomy specimen. It has been widely thought that increasing the surgical margin would lower the risk of the cancer returning in that breast.

Now a new guideline issued jointly by two medical organizations recommends against performing this second procedure following lumpectomy. The guideline is expected to save patients from unnecessary surgery while still minimizing the risk of the cancer returning.

“It was important for us to create this guideline because we want women to have the confidence to select a lumpectomy rather than a mastectomy when medically possible and breast cancer physicians to be confident about knowing when a margin is adequate,” says Monica Morrow, Chief of Breast Cancer Surgery at Memorial Sloan Kettering, who cochaired the new guideline development.

Dr. Morrow notes that some women with early-stage breast cancer choose to have a mastectomy (removal of the entire breast) rather than a lumpectomy due to fears of cancer recurrence.

Determining Risk of Recurrence

After conducting a review of the available scientific evidence, a panel of breast cancer experts from the Society of Surgical Oncology (SSO), the American Society for Radiation Oncology (ASTRO), the American Society of Clinical Oncology (ASCO) , the American Society of Breast Surgery (ASBS), and the College of American Pathologists (CAP), as well as patient advocates, found that removing additional tissue did not significantly decrease the risk of recurrence in the same breast in women who received radiation treatments to the entire breast, which is standard practice.

This was found to be true regardless of a woman’s age and whether she had one of the more aggressive, triple-negative cancer types.

Based on its findings, the multidisciplinary panel, which reviewed 33 studies involving 28,162 patients, developed comprehensive, evidence-based guidelines for lumpectomy margins in an effort to spare many women from unnecessary surgery.

“The definition of the appropriate surgical margin for breast cancer has been a major controversy for decades, but we see excellent outcomes in women who undergo lumpectomy followed by radiation therapy,” says Dr. Morrow.

In general, the ten-year survival rate is considered the same for both mastectomy and lumpectomy plus radiation therapy, but lumpectomy offers a faster recovery time and improved cosmetic outcomes while lowering total healthcare costs.

The new guideline is endorsed by the SSO, ASTRO, ASCO, and the ASBS. It can be downloaded on the SSO’s website, at www.surgonc.org/margins-study. Additional resources can be found in the SSO’s Annals of Surgical Oncology.

The guideline was produced with a grant from the Susan G. Komen Foundation.

Comments

I don't understand. It seems as though 12.5 percent of women who have a lumpectomy have cancer cells at the edge of the lumpectomy specimen. Is this suggesting that it's OK for these women to walk around with cancer cells just to avoid unnecessary surgery? if I were in that 12.5 percent, I'd want those cells removed to reduce the risk of recurrence.

Dear Myra, we sent your inquiry to Dr. Morrow, who further clarified what the guideline says. She responded, "If cancer cells are at the edge or margin, then more surgery is needed. If cancer cells are only close to the edge, then removing more NORMAL breast tissue is not needed."

Thanks for your comment.

How about frozen section for margin status? Is it still being done for lumpectomies and revised margins?

Dear Anita, at Memorial Sloan Kettering, the assessment of margin status does not routinely involve evaluation by intraoperative frozen section because it can cause tissue artifacts that can limit accurate pathologic evaluation. Thank you for your comment.

Why is triple negative small cancer, stage 1 under 2 cm treated so aggressively if
Node status is negative.
How often are nodes found to have cancer cells in such early small cancers

Debra, we forwarded your questions to breast cancer experts Monica Morrow and Clifford Hudis. They explained that triple negative breast cancers are associated with higher risks of recurrence as compared to similarly sized tumors that have estrogen, progesterone, or HER2 expression, even when the nodes are negative. In addition, the only proven therapies for this subtype of breast cancer are surgery, radiation, and chemotherapy. Hence they are treated with these modalities when otherwise appropriate. They also said that the surgical treatment of triple negative cancer does not differ from the treatment of estrogen receptor-positive or HER2-positive cancers. Thank you for your comment.

Thanks. Complete mastectomy would reduce or eliminate the chance of
Local recurrace since no breast tissue is left??

It might be naive question. If small 1.5 cm triple negative cancer node negative and total mastectomy done. What are the chances of reurrance over years?
Any statistics or numbers? I am aware of multiple factors in addition.

Debra, unfortunately we are not able to answer these kinds of specific medical questions on our blog. If you'd like to make an appointment to speak with a Memorial Sloan Kettering doctor, you can call our Physician Referral Service at 800-525-2225 during regular business hours or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

How can 10 yr survival rate for stage 1 node-negative BC be same for mastectomy and lumpectomy/radiation? If there's a greater chance of local recurrence w lumpectomy them wouldn't the chance of a new invasive BC arising which may verb be node positive impact the 10-yr survival rate? Also why are 10 yr survival rates always quoted instead of 20?

Pamela, we sent your questions to Dr. Morrow, who responded, "The chance of local recurrence is the same after mastectomy and lumpectomy and radiation therapy. Many years ago when lumpectomy first started the risk of local recurrence was higher with that procedure, but that is no longer true. The majority of recurrences and deaths occur within ten years so that is why ten-year survival statistics are used. At 20 years there is a high rate of death from nonbreast cancer causes, which makes the statistics difficult to interpret." Thank you for your comment.

What would determine the choice ,after a lumpectomy and then radiation therapy which doesn't kill the cancer cells. why have radiation therapy if it doesn't eliminate the cancer . Why not have the mastectomy after the lumpectomy therapy? Who makes that determination and how does it come about.

All these decisions are very confusing one has to make and a clearer understanding would be helpful to lay people.

Ann, thank you for your comment. We consulted with Dr. Morrow who replied:

The choice to have a lumpectomy or mastectomy is made before any surgery is done. All visible cancer cells are removed with the lumpectomy. The radiation helps to reduce the risk of cancer coming back in the future. Today, the risk of cancer recurring in the breast after lumpectomy and radiationis quite low and more than 90% of women never have this problem. If cancer comes back in the breast after lumpectomy and radiation then a mastectomy is done. On rare occasions when lumpectomy is attempted and all the cancer cannot be removed, meaning the margins are not free of cancer cells, then a mastectomy is done.

Thanks for a welcome article. What is the minimum acceptable margin?

Paula, thank you for your comment. For guidance on the minimal acceptable margin, we suggest you consult the link that appears at the very end of the article.

I am confused. My margins came back positive for atypical cells, is that the same as cancer cells? . I am told it is not not cancer but abnormal cells and we do not know if they will turn to cancer therefore we will try again to get clean margins. Why wouldn't the radiation treatment and hormonal treatment be enough to prevent recurrence?

Regina, unfortunately we are not able to provide personal medical advice on our blog. We recommend you speak to your doctor about this. If you'd like to make an appointment to speak with a doctor at MSK you can call 800-525-2225 during business hours or go to http://www.mskcc.org/cancer-care/appointment for more information. You might also want to reach out to the National Cancer Institute's Cancer Information Service at 800-4CANCER for more general information. Thank you for your comment.

Dear Madam
My question is if following breast conservation surgery, margin comes focal positive for DCIS ,is Cavity shave required?

Regards
Dr Sanjit Kumar Agarwal
Fellow,Breast Oncosurgery
Tata Medical Center ,Newtown

Dr. Agarwal, thank you for your comment. Unfortunately, specific medical questions cannot be answered on this blog, but we recommend you consult the guidelines mentioned at the end of the above story. (A link is provided.)

I HAVE HAD BILATERAL LUMPECTOMIES - 10 YEARS APART. TODAY, IO YEARS FURTHER ALONG THE ROAD A MICRO RECURANCE HAS BEEN FOUND.
I AM TORN ABOUT WHETHER TO HAVE A LUMPECTOMY AGAIN (3RD) OR A BILATERAL MASTECTOMY AND RECONSTRUCTION.
DOES A RECURANCE SIGNIFY A GREATER LIKLIEHOOD OF METASTISIS?

Dear Sands, we are sorry to hear that you have experienced a recurrence. Unfortunately, we can't answer personal medical questions on the blog. If you would like to consult with one of our specialists, please make an appointment through our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

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