Past
Surgeons have long demonstrated a bias toward mastectomy over breast conservation treatment (BCT) for the surgical management of patients with multiple ipsilateral breast cancer (MIBC). This practice evolved from retrospective data reported in the 1970s and 80s documenting prohibitively high risk of local recurrence in women with MIBC treated with BCT. At the time these data were collected, tumors were largely more advanced (pre-screening mammography), margins were assessed poorly or not at all, and patients did not receive targeted therapies. As these practices improved, retrospective studies from the 1990s and 2000s began reporting lower local recurrence rates with BCT in patients with MIBC, more similar to those of women with unifocal disease.1
Present
As breast imaging continues to improve and MRI is increasingly utilized for surgical planning, the pre-operative detection of MIBC is increasing. Studies in women with unifocal disease have demonstrated that BCT can lead to better quality of life and patient satisfaction in comparison to mastectomy with or without reconstruction. While some women may choose to undergo mastectomy, the option of BCT can be critical to long term physical and psychological recovery in women desirous of breast preservation.
Despite retrospective data demonstrating acceptable oncologic outcomes in women undergoing BCT for MIBC2, surgeons remain reluctant to offer BCT due to concerns regarding feasibility (risk of conversion to mastectomy), fear of poor oncologic results, inability to adequately administer radiation with larger resection cavities, persistent concerns regarding local recurrence and concern regarding cosmetic outcomes.
The recent reports from the Alliance Z11102 trial, which prospectively studies women with MIBC treated with BCT and radiation demonstrated the feasibility of BCT in the MIBC population with 7% of patients with 2 or 3 sites of disease requiring mastectomy3. Additionally, patient reported outcomes from this study confirm cosmetic results equivalent to those reported by patients with unifocal disease in other trials.4 Patients are currently being followed and 5 year local recurrence data from this trial is awaited.
Current NCCN guidelines support the use of BCT in the MIBC population in whom negative margins can be achieved through a single incision.5 Women with MIBC should participate in shared decision making with their surgeon to plan the best, individualized surgical approach.
Future
As oncoplastic techinques are increasingly adopted, the indications for BCT with an acceptable cosmetic outcome continue to broaden. Simultaneously radiation delivery and systemic therapies will continue to improve rendering more aggressive surgery less impactful. The Alliance Z11102 primary end point is local recurrence. These data will mature in 2022 and will providecritical, prospective information regarding the oncologic safety of BCT in MIBC. The British MIAMI trial will provide additional data regarding oncologic outcomes from BCT in MIBC. The outcomes from these prospective trials will help guide future decision making for patients with MIBC.
Acknowledgments
Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Numbers U10CA180821 and U10CA180882; UG1CA233290, UG1CA233329, and UG1CA232760. Dr. Judy Boughey discloses funding from the NCI to Alliance for Clinical Trials in Oncology group for travel to Alliance meetings. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
References
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