Surgeons Discuss Patient Selection Criteria for Breast Conservation

BOSTON--Radical mastectomy is no longer routine for women withbreast cancer, but the indications for breast conservation arestill being debated by surgeons who fear the risk of breast cancerrecurrence. At the 48th Annual Cancer Symposium, sponsored bythe Society of Surgical Oncologists, a panel of physicians discussedpatient selection criteria for breast conservation surgery.

Monica Morrow, MD, of the Northwestern University Medical School,emphasized the need to consider breast conservation in all womenwith breast cancer. If given the opportunity to choose, she said,"80% of all women greater than 70 years of age will selectbreast conservative techniques. It's a physician perception thatelderly women don't care about preserving their breasts."

She recommends magnification mammography to select patients forbreast conservation and plan the extent of resection. Criteriafor selection include the size, depth, and location of the tumor,in addition to the histologic features of the cancer. Performingwide excision is not always necessary, Dr. Morrow said.

Minor variations in cosmetic outcome are seen on the basis ofbreast size, but it is really the tumor-to-breast-size ratio thatis important, not absolute size, she said. The amount of tissueresected is the main determinant of cosmetic outcome, and a limitedresection results in good to excellent cosmesis in 90% of patients.

Surgeons differ on just how wide an excision needs to be to counterbalancethe risk of local recurrence. "Excisional biopsy is not anadequate therapeutic event," argued David S. Robinson, MD,of the Sylvester Comprehensive Cancer Center, Miami.

He recommends breast conservation therapy only for tumors lessthan 3 cm in diameter, and with a margin of at least 2 cm forextensive ductal carcinoma in situ (DCIS).

All the surgeons on the panel recommended dialogue among the radiologists,pathologists, and plastic surgeons in order to plan the extentof resection.

Risk Factors for Recurrence

Only a small percentage of patients treated with conservativesurgery and radiation therapy develop recurrence in the treatedbreast, said Stuart J. Schnitt, MD, associate director of surgicalpathology, Beth Israel Hospital, and associate professor of pathology,Harvard Medical School.

Potential risk factors for local recurrence include the extentof surgical resection, extensive intraductal component (EIC),and microscopic margins of excision, he said.

EIC is defined as infiltrating ductal carcinoma with prominentDCIS within the tumor and DCIS in adjacent tissue. Dr. Schnittbelieves that mammography is "critically important"in determining whether a patient is positive for EIC, whetherthere are diffuse malignant calcifications, and hence whetherthe patient is a candidate for breast conservation therapy.

Though EIC-positive tumors are more likely to have margin involvement,the presence of an EIC is not ipso facto a contraindication toconservative surgery with radiotherapy, Dr. Schnitt said. Rather,it is an indicator that a wider excision may be necessary to achieveoptimal local control.