Breast-Sparing Surgery Means More Procedures
By Kristina Fiore, Staff Writer, MedPage Today
Published: April 06, 2012
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania.
Breast-conserving surgery (BCS) has become a common treatment for patients with ductal carcinoma in situ (DCIS), but the rate of subsequent diagnostic imaging and invasive breast procedures following BCS is not known.
This study suggests that women with DCIS who choose to preserve their breasts with BCS may be subject to a high rate of subsequent diagnostic imaging and invasive breast procedures and may not be aware of this potential outcome.
Women with ductal carcinoma in situ (DCIS) who opt to preserve the affected breast face continued diagnostic and invasive procedures potentially for years after surgery, researchers found.
Over 10 years, more than 75% of women who underwent breast-conserving surgery subsequently had either a diagnostic mammogram or an invasive procedure in the same breast, Larissa Nekhlyudov, MD, MPH, of Harvard, and colleagues reported online in the Journal of the National Cancer Institute.
Most procedures occurred in the first six months after surgery, but about half of women still had a procedure during those 10 years even when that first half-year was excluded, they reported.
"The fact that women undergoing breast-conserving surgery are likely to have diagnostic and invasive breast procedures in the conserved breast over an extended period of time is important and needs to be included in discussions about treatment options," they wrote.
Breast-conserving surgery is the most common treatment for DCIS, but it's not known how often women who have the procedure have subsequent evaluations and procedures.
So Nekhlyudov and colleagues assessed 2,948 women with DCIS who underwent breast-conserving surgery from 1990 to 2001, and who were followed for up to 10 years.
During that time, 30.8% of the women had diagnostic mammograms to evaluate new symptoms or new abnormalities on a breast exam or on surveillance mammograms.
Most women — 61.5% — also had at least one ipsilateral invasive procedure over the study period, the most common being an excisional biopsy, they found.
Women who had adjuvant radiation had the highest rate of diagnostic mammograms (34.9%) while those on tamoxifen alone had the lowest rate (22.3%). The results were similar for invasive procedures, the researchers said (64.7% and 49.2%, respectively).
Invasive procedures were most common in the first six months: 51.5% of women had them during this time, and these procedures continued at a median annual rate of 3.1%.
Most diagnostic mammograms, on the other hand, occurred during the second year after surgery (11.4%), with 7.3% of women having one in the first six months. The median annual rate was 4.3%.
In cumulative, 10-year incidence estimates, 41% of women had at least one diagnostic mammogram, 65.7% had at least one invasive procedure, and 76.1% had either event.
When excluding events that occurred during the first six months after breast-conserving surgery, 36.4% had at least one diagnostic mammogram, 30.4% had at least one invasive procedure, and 49.5% had either one over 10 years, the researchers said.
They concluded that the frequency of ongoing diagnostic breast evaluations and procedures after surgery should be included in discussions about treatment.
One limitation of the study, they added, is that it potentially underestimates imaging and invasive procedures because women who had a full mastectomy within six months of breast-conserving surgery were excluded. It may also be limited in its generalizability because the data are from only three healthcare delivery systems, they said.
In an accompanying editorial, Joann Elmore, MD, MPH, of the University of Washington in Seattle, and Joshua Fenton, MD, of the University of California Davis in Sacramento, Calif., agreed that these data should be incorporated into the decision-making process about breast-conserving surgery.
"Women who choose to preserve their breasts with breast-conserving surgery may be embarking on a more extended journey than anticipated," they wrote. "Unfortunately, not all women may be aware of this potential outcome when they consider their treatment options."
"Concerns about the substantial risk of subsequent invasive procedures may possibly sway more women to choose initial mastectomy over breast-conserving surgery," they wrote.
The study was supported by grants from the National Cancer Institute.
Neither the researchers nor the editorialists reported any conflicts of interest.
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