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• Fig. 18.4 Following mastectomy and tissue expander placement, the
tissue expander is inflated in preparation for the second stage of permanent implant placement.
reconstruction (immediate versus delayed).58 Infection and
wound breakdown leading to expander/implant loss are also
increased in this group.61 Reported total complication rates
for prosthetic reconstruction following salvage mastectomy
range from 29.7–70% (compared with 10–30% without
radiotherapy).
is reported from 15–40%.
54,62-65
Loss of prosthesis in this patient group
61,62,65,66
Skin ap necrosis ranges
from 12–18% (vs 7.7% without radiotherapy), and therefore prudent evaluation of skin ap perfusion intraoperatively is required to determine device volume.
63,66
McCarthy et al highlighted the patients at risk of
increased complications from prosthetic reconstruction.67
ey report a substantial increased risk of reconstruction failure in patients with high body mass index (odds
ratio [OR] 7.0), tobacco users (OR 5.0), and hypertensive
patients (OR 4.0). Complication rates are twofold higher
in smokers, and obese and hypertensive patients. Patients
over the age of 65 years are also at increased risk of complications in prosthetic reconstruction.
66,67
ere is little evidence to suggest postoperative chemotherapy is associated
with worse outcomes.65 In these groups of patients, prosthetic reconstruction following salvage mastectomy should
be carefully considered and alternatives explored. For this
reason, delayed or immediate autologous reconstruction
is preferential.65 In selected patients who do not wish to
undergo autologous reconstruction, prosthetic reconstruction is a viable option, provided that they accept the higher
risk of complications and reconstructive failure.
e choice of autologous reconstruction will be determined by patient factors and surgical preference. Careful
patient evaluation and selection can produce good results
regardless of the reconstructive ap used.68 A variety of
autologous reconstructions are reported in this patient
subgroup including unipedicle Transverse Rectus Abdominis Myocutaneous (TRAM), free TRAM, Deep Inferior
Epigastric Perforator (DIEP), and latissimus dorsi (LD)
musculocutaneous ap with or without an implant.
68-72
Data published consists of small retrospective case series.
e majority of publications report on LD reconstructions.
Meta-analysis of LD with implant versus implant reconstruction alone favors autologous reconstruction, with a
clinically signicant reduction in device losses (15% vs
5%), infection, and reoperations73 for LD patients. Capsular contracture in these patients ranges from 3–12.5%
in dierent series.
71,74
e complication rate for LD with
implant following salvage mastectomy is approximately
70,72
30%.
Van Huizum et al report a 94% reconstruc-
tion success rate with this technique (n = 93).72 e most
commonly reported complication was donor site seroma.
Authors recommend this technique as a good solution in
the postirradiated breast.75 To avoid the prosthesis-related
complications, autologous fat grafting to the LD ap can
be considered to add further volume to the LD ap.76 Figs.
18.3 and 18.4 illustrate a patient following left breast con-
servation, radiation, and recurrence managed with mastectomy and autologous reconstruction.
Outcomes for delayed abdominal reconstruction (TRAM/
DIEP) versus delayed LD with implant in the context of
salvage mastectomy were compared in a small retrospective
case series.70 Overall there was no signicant dierence in
complications between the two procedures (28% vs 30%).
e reconstructive failure rate was noted to be higher in the
implant group (5.4% vs 2.7%) secondary to infection; however, it still remains low in comparison to device losses in
prosthetic reconstruction alone.70 e choice of autologous
breast reconstruction and its timing in patients undergoing
mastectomy for recurrence remains complex and needs to
take into account numerous patient factors both preoperatively and intraoperatively to achieve the best results.
Conclusions
Local recurrence following oncoplastic breast surgery is a
concern; however, current rates are similar to mastectomy.
Close surveillance is required for all patients following BCS.
Local recurrence options include a second excision versus
mastectomy and will depend on extent of tumor and clinical judgment.
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19
https://t.me/medicina_free
Surveillance and Imaging Following
Oncoplastic Breast Surgery
TONI STORM-DICKERSON AND ALLEN GABRIEL
In this chapter, we will lay out the rationale for screening
mammograms to start at age 40 and continued annually
until age 70, at which time biannual imaging should be performed until life expectancy is less than 5 years, or a patient
refuses intervention of any kind. Exceptions for high-risk
patients are addressed later in the chapter. We will also list
the current guidelines and recommendations set forth by
our leading societies
Overview
In the United States, the 5-year survival rates for women
with breast cancer have improved from 75% in 1975–1977
to 90% in 2003–2009.1 e risk of distant or metastatic disease and death increases with both tumor size and number
of axillary lymph nodes involved.
phy is not a perfect test and may be particularly insensitive
at detecting breast cancer among selected groups of patients,
such as those with very dense breasts, extensive scaring from
previous interventions (such as surgery and radiation), or
those with a subtype of malignancy that is often harder
to detect on imaging such as invasive lobular carcinoma,
it remains eective at nding smaller tumors before they
are palpable.
tion, as when measuring the harm, survival should not be
the only measure of ecacy. After tumor size and lymph
node involvement, survival is strongly inuenced by tumorrelated factors such as hormone receptor and human epidermal growth factor receptor 2, (HER-2) status, and grade.
Screening mammography is eective at nding more (not
all) cancers earlier, before they are palpable, and thereby
reducing the number of women with cancers of advanced
size and stage. Finding cancers at an earlier stage allows for
better outcomes, more lives saved, and potential for both less
extensive surgery and either no or potentially less extensive
chemotherapy. us, mammography meets the criteria of
an eective screening test: (1) detects disease at a stage when
an intervention can make a dierence, and (2) is aordable,
accessible, and does not cause more harm than good.
6-9
When measuring the benet of an interven-
2-5
Although mammogra-
3-5,10
Imaging in Women 40–70 Years of Age
Breast cancer is common, aecting about 1 in 8 women
(12.5%) with more than 260,000 new cases per year in the
United States.11 As of January 2018, there were more than 3.4
million women either with a history of breast cancer or being
treated for breast cancer in the United States alone.12 Less than
1% of breast cancers develop in men. Not including benign
breast biopsies and cosmetic breast surgery, there are more than
a half-million breast cancer-related surgeries performed per year
in the United States.13 In spite of all this breast cancer surgery,
breast imaging recommendations remain controversial, with
the United States Preventive Services Task Force (USPSTF) recommendations diering, in varying degrees, from most of our
other guiding bodies: American College of Radiology (ACR),
American Cancer Society (ACS), and American Society of
Breast Surgeons (ASBrS)/Society of Surgical Oncology (SSO).
In part, the controversy arises secondary to the fact that
breast cancer is not only common, it is potentially deadly but
not uniformly so. Breast cancer represents about 20% of all cancers (men and women) and is the second most common cause
of cancer death among women overall.15 is number continues to improve in women over 50, with breast cancer deaths
having dropped by approximately 37% between 1989–2015
in this population16 (Table 19.1, with annex). Breast cancer
screening guidelines from the various cancer organizations are
listed in tables 19.2-19.4. However, in women under 50, the
death rate has remained steady since 2007. Data has also shown
that younger women are more likely to develop more aggressive
malignancies (HER2-positive and hormone receptor-negative)
with higher risk of both distant and local recurrence.
Breast cancer is often thought of as a disease of the
elderly, which is not untrue (Figs. 19.1 and 19.2). However, this is a very limited picture of the true impact and
distribution of the disease. Breast cancer is most commonly
diagnosed in middle-aged women with a broad distribution
extending to the young adult and the very old. As stated
earlier, the “lifetime” risk of developing breast cancer is 1
in 8 women, with 25.9% of all breast cancers diagnosed
14
17-25
158
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TABLE
19.1
The USPSTF Average Risk Breast Cancer Screening Guidelines, 2015
59
Population Recommendation
Women aged 50—74
years
Women aged 40—49
years
Women aged 75 years
or older
All women The USPSTF concludes that the current evidence is insufficient to assess the benefits
Women with dense
breasts
These recommendations apply to asymptomatic women aged 40 years or older who do not have preexisting breast cancer or a previously diagnosed
high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as a BRCA1 or BRCA2 gene
mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age.
The USPSTF recommends biennial screening mammography for women aged 50—
74 years.
The decision to start screening mammography in women prior to age 50 years should
be an individual one. Women who place a higher value on the potential benefit than
the potential harms may choose to begin biennial screening between the ages of 40
and 49 years.
• For women who are at average risk for breast cancer, most of the benefit of mammography results from biennial screening during ages 50—74 years. Of all of the
age groups, women aged 60—69 years are most likely to avoid breast cancer death
through mammography screening. While screening mammography in women aged
40—49 years may reduce the risk for breast cancer death, the number of deaths
averted is smaller than that in older women and the number of false-positive results
and unnecessary biopsies is larger. The balance of benefits and harms is likely to
improve as women move from their early to late 40s.
• In addition to false-positive results and unnecessary biopsies, all women undergoing
regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to
their health, or even apparent during their lifetime (known as “overdiagnosis”). Beginning mammography screening at a younger age and screening more frequently may
increase the risk for overdiagnosis and subsequent overtreatment.
• Women with a parent, sibling, or child with breast cancer are at higher risk for breast
cancer and thus may benefit more than average-risk women from beginning screening in their 40s.
Go to the Clinical Considerations section for Information on implementation of the C
recommendation.
The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of screening mammography in women aged 75 years or older.
and harms of digital breast tomosynthesis (DBT) as a primary screening method for
breast cancer.
The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to
have dense breasts on an otherwise negative screening mammogram.
Grade (What’s
This?)
B
C
I
I
I
Grade Definition Suggestions for Practice
A The USPSTF recommends the service. There is high certainty that the net
benefit is substantial.
B The USPSTF recommends the Service. There is high certainty that the net
benefit is moderate or there is moderate certainty that the net benefit is
moderate to substantial.
C The USPSTF recommends selectively offering or providing this Service to
individual patients based on Professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
D The USPSTF recommends against the Service. There is moderate or high
certainty that the Service has no net benefit or that the harms outweigh
the benefits.
I
Statement
The USPSTF concludes that the current evidence is insufficient to assess
the balance of benefits and harms of the Service. Evidence is lacking,
of poor quality, or conflicting, and the balance of benefits and harms
cannot be determined.
Offer or provide this Service.
Offer or provide this Service.
Offer or provide this Service for selected
patients depending on individual circumstances.
Discourage the use of this Service.
Read the clinical considerations section of
USPSTF Recommendation Statement.
If the Service is offered, patients should
understand the uncertainty about the
balance of benefits and harms.
SECTION III Oncoplastic Breast Surgery – Outcomes
Trends in death rates, 1930–2014
Rate per 100,000 population
Per 100,000, age adjusted
2014
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TABLE
• History of breast cancer
• Genetic mutation
• History of chest XRT
• Fig. . Declining death rate 37% between 1989–2014 for women
over 50. (Data taken from the American Cancer Society SEERS Data,
NIH 2016.)
American Cancer Society (ACS) 2015 Average
19.2
Risk Breast Cancer Screening Guidelines
Risk Age Recommendation
Average 40-44 Shared decision-making process for
Average 45–54 Annual screening
Average Over 55 Biennial screening
ACS acknowledges definition of average risk is broad and excluded only:
Intermediate risk group that may require a different screening approach
35
30
25
20
15
10
5.0
0.0
between the ages of 55 and 64 with an average age of 62 at
diagnosis (see Fig. 19.2). However, it is extremely important
to note that there is an almost equal distribution 10 years
above and below this, with 20.4% of women diagnosed
between 45–54 years of age and 24.1% diagnosed between
65–74 years of age. Context remains extremely important
as seen in Fig. 19.3, with lifetime risk seen to be highest in
women age 80; however, the age at which a large number of
women are diagnosed is 62 (see Fig. 19.3). Again, we must
note that survival improves with earlier stage at diagnosis;
women to elect screening
Elderly Continued screening as long as life
expectancy greater than 10 years
Breast (female), by sex
Female
1930 1980
Year
5 years survival for stage I breast cancer is 98.7% compared
60
with 27% for metastatic disease.
26
It is a known fact that the vast majority of breast can-
cers are spontaneous at 85–90%
26-27
; thus, lacking a family history cannot be interpreted as protective but rather
just another unknown. Using lack of a family history as an
indication for mammography exclusion before the age of 50
leaves a large and vulnerable group of “average risk” women
with a misimpression that they are somehow safe and will
not benet from screening mammography. us, in context
of previously presented information, what are the current
recommendations for breast imaging set forth by the USPSTF and what is the rational for these recommendations?
e original recommendations, set forward in 2002, used a
meta-analysis of eight large prospective mammography trials designed to assess the eectiveness of mammography in
reducing breast cancer mortality but only included data from
seven trials.28 All the trials had limitations, but the USPSTF
excluded the Edinburgh study from the analysis, secondary
to imbalance between the control and screened groups. USPSTF concluded: “Mammography reduced breast cancer mortality among women 40–74 years of age with a greater benet
in women greater than 50” and at that time continued to
recommend mammograms annually starting at age 40.
In 2009, the USPSTF updated their analysis to include
data from the AGE trial from the United Kingdom that
randomized women aged 39–41 to annual screening mammography until age 48.29 e purpose of their evaluation
was to “determine the eectiveness of mammography
screening in decreasing breast cancer mortality among average-risk women aged 40 to 49 years and 70 years or older,
the eectiveness of clinical breast examination and breast
self-examination, and the harms of screening.” ey published their results in Annals of Internal Medicine, November 2009. e study used lm and digital mammography,
and the Task Force again found a 15% reduction in breast
cancer mortality in favor of screening with an even greater
benet for women over 60. ey reported the false-positive rate highest in women aged 40–49 with the highest
rate of additional imaging and unnecessary biopsies in this
age group. Secondary to their concerns for the harm benet ratio, they changed their recommendations to consider
starting mammographic screening at age 50. Further, they
found no benet for clinical breast examination, and selfbreast examination was considered harmful.
In their conclusion, they stated that “Our meta-analysis
of mammography screening trials indicates breast cancer
mortality benet for all age groups from 39 to 69 years,
with insucient data for older women. False-positive results
are common in all age groups and lead to additional imaging and biopsies. Women aged 40 to 49 years experience the
highest rate of additional imaging, whereas their biopsy rate
is lower than that for older women. Mammography screening at any age is a tradeo of a continuum of benets and
harms. e ages at which this tradeo becomes acceptable
to individuals and society are not clearly resolved by the
available evidence.”
30
TABLE
Percent of New Cases
300
Age
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American College of Radiologist (ACR) Average Risk Breast Cancer Screening Guidelines, 2018
19.3
Risk Age Recommendation
High
Age 25 or 8 years after radiation Annual screening
Chest radiation before 30
High-genetic based increased risk and
25–30 Annual mammogram and consider MRI
their untested 1st degree relatives,
those with >20% lifetime risk
High personal history of breast cancer Start at diagnosis or 40 whichever
Annual mammogram and if <50 consider MRI
comes first
High personal history of ADH, ALH 40 Annual screening and consider MRI especially if other
risk factors are present
Average 40–75 Annual screening
Average Elderly Annual screening until life expectancy less than 5–7
years
Without Tomosynthesis, should be performed annually.
ADH, Atypical ductal hyperplasia; ALH, atypical lobular hyperplasia; LCIS, lobular carcinoma in situ.
MRI should be considered, especially if other risk factors are present.
TABLE
American Society of Breast Surgeons (ASBrS) in Conjunction with the Society of Surgical Oncology (SSO),
19.4
Breast Cancer Screening Guidelines
Risk Age Recommendation
Average 40–44 Consider screening based on a discussion of risks and benefits
Average 45–54 Annual screening mammograms
Average 55 and older Annual or biennial screening for women 55 and older based on a
shared decision
Average Older than 75 with life expectancy greater
Biannual screening mammogram
than 10 years
Asymptomatic
Intermediate
40 and older Consider use of annual screening mammography for women with
greater than an estimated 15% lifetime risk for breast cancer
Risk
Asymptomatic
High Risk
10 years younger than the 1st degree relative,
or 10 years after chest wall XRT, or by age
40, whichever comes first
Recommendations for asymptomatic high-risk women (20–25% or
greater estimated lifetime risk) annual mammography and MRI
compliant with ACS and NCCN guidelines
25.8%
250
200
150
100
50
22.8%
8.7%
1.8%
0
20–34
35–44 45–54
55–64
23.4%
13.8%
65–74 75–84 >84
• Fig. . Breast cancer: percentage of new cases per year, by age (SEER data).
5.6%
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162
Age-Specific Rates of Breast Cancer in the United States
500
450
400
350
300
250
30–34
22.8%
35–39
40–44
200
150
100
Number of breast cancer cases per 100,000 women/men each year
50
1.8%
0
0–14
15–19
20–24
8.7%
25–29
• Fig. . Age-specific rates of breast cancer overlaid with percentile distribution of breast cancers per
year by age (SEER data).
Of very signicant import is that the USPSTF’s primary concern with mammography was not its ability to
detect cancers earlier than would be found without imaging and thereby prevent breast cancer-related deaths, but
rather harm of imaging outweighing the benet based on
unnecessary imaging and biopsies as well as costs. With
this in mind, note their studies used plain lms and digital mammography. We now have 3D breast tomosynthesis widely available, which has shown a reduction in false
positives by 17.1% and an increase in the rate of cancer
detection of breast cancers by 33.9% over standard digital
mammography.
31
If we combine (1) the improved diagnostics of tomosynthesis with fewer false positives and better detection rate (2)
with the proven, at least, 15% decrease in mortality with
early diagnosis through mammography and (3) the fact that
women under 50 account for approximately 24% of breast
cancers diagnosed per year and tend at a productive time in
life with young children contributing to society, (4) to have
more aggressive disease that will progress rapidly and cost
more to treat, (5) and are very unlikely to be considered
25.8%
23.4%
13.8%
5.6%
Men
85+
80–84
45–49
50–54
Age (years)
55–59
60–64
65–69
70–74
75–79
“high risk” and thus quality for imaging under the current
guidelines, a strong argument can made to resume annual
mammograms starting at age 40.
The Argument Against Imaging
It is also important to address the work of Gilbert Welch
etal. eir paper, published in the New England Journal of
Medicine, October 2016,32 suggests that improved therapy
is solely responsible for the huge survival benet seen in
the most recent SEER data16 rather than any benet from
screening mammography or early detection. Although it is
very true, a better understanding of biology and improved
treatments are clearly a large part of the overall survival picture; it is not the entire story, and new data does not support
claims of “rampant overdiagnosis.” e Welch et al paper
reiterated the SEER data nding of a 30% decrease in large
tumors found in American women following the advent of
screening mammography. is correlates directly with an
increase in detection of small invasive cancers. Further, several studies, including those by Otto etal and Coldman and
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163
Phillips, have shown that, in women who regularly undergo
screening mammography, the risk of dying from breast cancer is cut nearly in half.
33-34
Plevritis etal35 nicely illustrated the changes seen in the
screening/treatment association with breast cancer mortality by molecular subtype in U.S. women in 2000 contrasted
with 2012 in their recent article. ese authors looked at
the six Cancer Intervention and Surveillance Network (CISNET) models that simulated U.S. breast cancer mortality
from 2000–2012 for women aged 30–79. In 2000, the
overall estimated reduction in breast cancer mortality rate
was 37%, 44% (model range, 35–60%) from screening and
56% (model range, 40–65%) from treatment. In 2012, the
estimated reduction in overall breast cancer mortality rate
was 49%, 37% (model range, 26–51%) from screening and
63% (model range, 49–74%) from treatment. Of the 63%
associated with treatment, 31% (model range, 22–37%) was
attributed to chemotherapy, 27% (model range, 18–36%)
to hormone therapy, and 4% (model range, 1–6%) to
trastuzumab.
Baseline growth of breast cancer is also a critical factor
in determining overdiagnosis. Puliti et al published their
results, based on actual patient data, showing a more than
1% per year increase in breast cancer diagnosis from 1940–
1974, the start of the SEER program.36 If Welch et al, in
their 2012 paper, had used 1% percent breast cancer incidence growth rate, the ndings would have been vastly different, showing no evidence of overdiagnosis and a marked
decline in advanced cancers, which has led the decline in
breast cancer death since screening began.
37
Sepideh etal38 looked at 173,797 women in the Netherlands diagnosed with breast cancer between January 1999
and December 2012 to assess survival dierences based
on changes in chemotherapy subdividing them into two
groups (1999–2005 and 2006–2012) to reect changes in
chemotherapy over time, with the cut-o primarily chosen
to reect the advent of trastuzumab.39 eir study included
large populations of breast cancer patients with 80,228
(46%) diagnosed from 1999–2005 and 93,569 (54%) from
2006–2012, with a median age at diagnosis of 59.3 years
and 60.0 years, respectively. ey found that those women
diagnosed between 2006–2012 had signicantly smaller
tumors, were more often lymph node negative, and were
more likely to have breast conservation therapy (BCT)
and to receive systemic therapy and radiation. Hormonal
therapy increased by 10%, chemotherapy by 7%, targeted
therapy (mainly trastuzumab) by 7%, and a combination of
therapies by 7%.
is translated into a 100% relative survival for ductal
carcinoma in situ (DCIS) after 15 years in the 1999–2005
cohort and 101% after 8 years for the 2006–2012 cohort.
Overall, the relative survival decreased with increasing
tumor and nodal status. ey found a 17% increase in
the diagnosis of breast cancer between the two time periods, noting a very signicant increase in the aging female
population. During the study time frame, the Dutch female
population grew by approximately 2.7%, and the female
population aged 60–69 years grew by approximately 23%.40
e median age at diagnosis was approximately 59 years,
with a peak associated with menopause (age 50–59 years).
In the later cohort, diagnosis included smaller tumors, more
often lymph node negative, and more often low grade compared with the earlier cohort. Five-year relative survival rates
improved over time to 100% in all tumors 1 cm or smaller
and to 98% for tumors between 1 and 2 cm, and improved
increasingly with larger tumor size. e relative survival
increased especially in women aged over 75 years.
e authors concluded that there is a dual benet to early
detection because as tumor size increases so does the likelihood of positive lymph nodes.38 ey found the inuence of
stage corrected for both tumor biology and treatment with
no dierence in hazard rate for breast cancers sized 1 cm
or smaller. Lymph node negative T1a and b tumors do not
receive chemotherapy in the Netherlands regardless of hormone status (i.e., estrogen receptor [ER] negative). Women
diagnosed between 2006 and 2012 had BCT and axillary
lymph node dissection less often, secondary to adoption of
sentinel lymph node biopsy.41 Surgery remains the cornerstone of treatment, and BCT has an equivalent survival to
mastectomy and has been shown to confer improved survival in many patients, which may be a reection of axillary
radiation.
Policy Implications for Women 40–70
Years of Age
Viewing the data in a new and more contextual manner
may aid both policymakers (USPSTF) and physicians in
clinical decision making, as well as providing patients with
less ambiguous recommendations regarding breast cancer
screening. Although the USPSTF has softened on its stance,
they remain committed to the recommendation of starting
screening mammography at age 50 and then every other
year. As the USPSTF guidelines determine insurance coverage, this has a critical eect on patients and policy. However,
the data support the idea that, although systemic therapies
and prognosis have improved, so too has breast imaging. We
have shown (1) that improved survival is associated with
smaller and node negative tumors, (2) breast imaging has
also improved with fewer false positive and improved cancer
diagnosis, (3) that the vast majority of breast cancers in women
between 40–49 years (and indeed all women) are spontaneous, and (4) increased risk of more aggressive disease in this age
group require more extensive interventions, lost productivity,
and expense. Together, these make a strong argument for breast
cancer screening to start at age 40. Mammography remains
an excellent, although imperfect, screening tool for all women
starting at age 40 and continuing until age 70.
Breast Imaging After 70 Years of Age
Recommendations on breast imaging after 70 were not
put forth by the USPSTF secondary to lack of data
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