Treatment of early breast cancer with conservation of the breast. A review

The case against routine preoperative breast MRI

In patients with primary breast cancer, preoperative MRI identifies additional foci of tumor in the ipsilateral or contralateral breast that are not evident with standard imaging. Breast cancer patients who are otherwise deemed suitable candidates for breast-conserving surgery might, therefore, be urged to undergo mastectomy or even bilateral mastectomy following staging with preoperative breast MRI. The effect of preoperative breast MRI on clinical end points (rates of ipsilateral breast tumor recurrence) and surgical end points (rates of reoperation) have been assessed in several large studies. These studies indicate that the routine use of preoperative breast MRI is not beneficial. The additional occult foci of tumor detected with preoperative breast MRI seem to either have no clinical significance, or can be adequately treated with radiotherapy and/or systemic therapy. This article reviews these studies and highlights the potential harms associated with the routine use of preoperative MRI in patients with primary breast cancer.

Quality of systematic reviews used in guidelines for oncology practice

BACKGROUND

Systematic reviews are an important tool for developing clinical recommendations. Those of high quality assure a good level of confidence on the strength of the recommendations.

METHODS

A QUOROM-based checklist was applied to the reviews cited in a sample of guidelines on breast and colon cancer prevention and therapy. The checklist provided a weight for each criterion and a total quality score. Each review was independently evaluated by two reviewers; disagreements were solved by consensus.

RESULTS

Eighty reviews (96%) were retrieved and evaluated; 36 focused on breast, and 44 on colorectal cancer. Twenty-three reviews (29%) did not match the definition of systematic review. In 17 (21%) the searching methods were unclear or described elsewhere. Forty (50%) were systematic. Not systematic, low and very low quality reviews accounted for 70% of the total. No review obtained the A+ class score; only 5 (6%) the A- and 7 (9%) the B+.

CONCLUSIONS

The results of this assessment provide a sober picture of the quality of the sources used to build guidelines. Oncologists should be aware that they could be relying on poor underlying documents. Writing groups should be aware of methodological problems, and should consult the existing manuals for the preparation of guidelines.

The pattern of diagnosis of a second primary tumor in the breast

One hundred and sixty-seven patients with metachronous bilateral breast cancer were diagnosed at the Northern Israel Oncology Center during the years 1950-1989. The group at high risk to develop a second breast tumor included Jewish women born in Europe whose first tumor was diagnosed when the patient was under the age of 55. The mean time interval between tumors was 88 months. Seventy percent of the patients were diagnosed within nine years of the diagnosis of the first tumor. The characteristics of the 27% of patients with single breast cancers who did not comply with follow-up recommendations were compared to those who did comply. Patients who were under follow-up had smaller tumor and less lymph node involvement. Nevertheless, their survival rate did not differ from those who did not keep their follow-up appointments. This was ascribed to the fact that follow-up procedures for many years used mainly clinical examination and this was not enough to decrease mortality. The diagnosis of non-palpable breast cancer by routine yearly mammography has proved to reduce mortality in patients over the age of 50 with single breast cancers. Therefore, yearly mammography of the contralateral breast in patients with single breast tumors must be done in order to increase the cure rate of contralateral breast cancer. Less patient delay in diagnosis was found before the diagnosis of the second tumor than in patients with a single tumor.

Breast-conserving therapy for mammary carcinoma: psychosocial aspects, indications and limitations

Breast-conserving therapy (BCT) for invasive cancer comprises complete tumour excision and axillary dissection, followed by irradiation. The object is to perform local treatment and determine the stage of disease on lines similar to those of mastectomy. In selected series of patients the efficacy of BCT has been equivalent to that of mastectomy with a view to distant relapse and survival. On the other hand, it has not been proved whether local relapse pattern is comparable to that of mastectomy, especially in high-risk patients. The advantage of BCT is of psychological nature, since preserving the configuration of the body maintains the sensation of female identity and body image to a better extent than that seen after mastectomy. BCT does not, however, reduce the high frequency of anxiety phenomena, mental instability, and depression. The selection of patients for BCT is based primarily upon a clinical-technical assessment, patient's preference and surgeon's preference, rather than eligibility based on biological risk factors. Demands on surgical technique, radicality of operation, and irradiation are important issues regarding local control. The relation between local recurrence rate and distant relapse will be discussed. The conclusion is that BCT is a method eligible for selected patients and that the increased used of mammography is going to extend the intake of patients for the method. However, it must be an obligation to keep following up the therapeutic results, in order not to lose the advantage of an early diagnosis by altered treatment.(ABSTRACT TRUNCATED AT 250 WORDS)