Expert Q & A Series : Breast surgery
DailyRounds 7 Q&A with Dr Kanchan Kaur
Dr Kanchan is the Associate Director at Medanta Breast Service, Medanta — The Medicity
1. DailyRounds: Under what circumstances would you recommend performing an ALND?
Dr. Kaur: An axillary lymph node dissection is a procedure wherein the all the lymph nodes along with the axillary fat are excised as part of breast cancer surgical management.
Patients diagnosed with breast cancer undergo a clinical and radiological evaluation of the axilla with a USG/MRI. Patients in whom the axillary lymph nodes look suspicious, must undergo a USG guided FNAC of the node.
If this is reported as showing lymph node metastasis, then the patient proceeds to undergo clearance of the axilla during surgery.
In those patients where the lymph nodes are reported as normal on imaging, a sentinel node biopsy or four node sampling of the axilla must be done during surgery. If there is evidence of metastatic cancer cells in these lymph nodes, then the patient proceeds to a complete axillary dissection.
ALND can be avoided in patients who have micro metastasis in the sentinel lymph node (defined as a metastatic focus less than 2 mm in size)
There are trials going on in the West which are looking at the subset of patients in whom axillary dissection can be avoided even if they have sentinel node involvement.
2. DailyRounds: Post surgical neuropathic pain is often refractory to treatment. Can you recommend the best / most effective regimen?
Dr. Kaur: Patients undergoing breast surgery for cancer can develop a chronic pain syndrome known as post mastectomy pain syndrome PMPS. This pain may also manifest in patients who have had breast conservation surgery. It has been reported in about 20% to 68% of breast cancer patients. This may start in the early post operative period, but is also known to appear upto 6 months to a year after surgery.
Management of this pain requires a multi prong approach, the first of which is counselling and reassurance. For treated cancer patients, any sensation in the area of the scar brings up the worry of it being related to recurrence. Proper counselling is a must at this stage to allay fears.
The second important strategy is to motivate the patient to do stretching exercises starting in the early post operative period. This prevents muscle stiffness which is a common cause of post surgical pain. It may also promote the development of a supple soft scar instead of a stiff contracted painful scar.
For patients in whom simple measures as stated above don’t work, then we guide them on judicious use of painkillers (during phases of heightened pain) in a step ladder fashion. Simple analgesics like NSAID’S are used first and if patient does not achieve symptom relief, stronger painkillers like opioids are advised. For refractory pain affecting quality of life, drugs like pregabalin and antidepressants may be used. Local patches and injection of steroid and bupivacaine may also help.
3. DailyRounds: Do you think that the newer tumor markers have a sufficient cost benefit/ efficacy/ added benefit to be implemented in India in the future?
Dr. Kaur: Unlike certain cancers like ovarian, bowel and thyroid where there is a definite role of tumour markers in monitoring recurrence, there is no marker of proven clinical value in breast cancer. The three reported tumour markers for breast cancer are cancer antigen 15–3 (CA 15–3), cancer antigen 27.29 (CA 27.29), and carcinoembryonic antigen (CEA).
These are not recommended for routine use in clinical practice as they have no added clinical benefit.
4. DailyRounds: While the incidence of cervical cancer has reduced due to large scale screening, the incidence of breast cancers have remained high. How would you setup a breast cancer screening programme in India ?
Dr. Kaur: Breast cancer rates are rising at an alarming rate in India. Breast cancer is multifactorial and this makes it difficult to have a definite preventive strategy in place. Because of this it is important to have effective early detection programmes.
In the west, population based mammogram screening programmes have been shown to be associated with early detection which translates into better survival rates.
Unfortunately in India, 70–80 % patients present at a late stage thus leading to the dismally high mortality associated with breast cancer. Only 1 in 2 women diagnosed with breast cancer in India survives during the first 5 years.
Population based mammogram screening is not valid for a country like India because of logistics and quality control issues. The burning need of the hour is an all out aggressive awareness drive. Women need to learn the importance of self breast examination. They need to be taught to report any changes at the earliest to their health care providers. Various stakeholders both in the private and public sector need to take up this mission on a nationwide scale, like it has been taken for issues like family planning and TB. Ground level health workers need to be trained to educate women in the community.
Opportunistic screening should be offered to women who present to a doctor for other ailments and the opportunity to spread the knowledge about the importance of early detection should not be missed.
5. DailyRounds: Studies have shown that Thoracic Paravertebral Block for Breast Surgery has better outcomes, superior pain relief and decreased nausea, fewer postoperative side effects to GA. Would you agree?
Dr. Kaur: Paravertebral nerve blocks have been reported in various series to have better outcomes in pain relief for operated breast cancer patients.
However, I personally do not agree on using this for patients as a routine. Breast cancer surgery is not a very painful procedure. Patients very frequently report good pain control with analgesics like paracetamol, which we prescribe at a dose of 1 gm every 6 hours. Most patients stop using this within 2–3 days of surgery. For those patients reporting pain on paracetamol, addition of ibuprofen helps.
Presurgical assessment of the psychological status of the patient is important. For very anxious patients, a paravertebral block may be used after informed counseling.
6. DailyRounds: What risk reduction strategies can we adopt in BRCA positive women?
Dr. Kaur: Women who carry the BRCA mutation, need to be counselled about their risks. Strategies to reduce these have to be made in a multidisciplinary setting, which involves the breast surgeon, gynaecologist, and genetic counsellor.
The risk reducing strategies have to take into account the age of the patient, her childbearing status and assessment of how much of a threat she perceives for herself from her BRCA positive status.
Some women are not comfortable with the idea of having surgical removal of the organs at risk. Such women should be offered strict surveillance. The patient should be made to understand that this will not reduce the risk of developing a cancer, but if one develops, it will be picked early and treated accordingly.
Risk reducing interventions can be medical in the form of chemoprevention or surgical in the form of mastectomy and oopherectomy.
Regular Breast examinations beginning at age 18, may facilitate awareness of changes, and clinical breast examination should be performed every 6 to 12 months beginning at age 25.
Annual mammography — Mammography should begin at age 30 or be individualized if the earliest age of onset in the family is under age 25.
MRI for breast cancer screening is recommended annually beginning at age 25 and can be scheduled six months after annual mammogram
The option of chemoprevention (although not as effective) to reduce the risk of breast cancer involves the use of selective estrogen receptor modulators (SERMs) and aromatase inhibitors for breast cancer prevention.
Tamoxifen may be considered for risk reduction for women who opt against mastectomies, especially if they are BRCA2 mutation carriers. However, the option for prophylactic mastectomy should be rediscussed periodically with patients.
Risk-reducing bilateral mastectomy decreases the incidence of breast cancer by as much as 90 percent or more in patients at risk of hereditary breast cancer. The risk reducing mastectomies recommended for risk reduction involve sparing the skin and nipple alongwith primary reconstruction.
For BRCA mutation carriers, risk-reducing BSO is recommended for women who have completed childbearing, and should be performed by age 35 to 40 or individualized based on age of onset of ovarian cancer in the Family
NCCN Guidelines for Risk Management for Women with BRCA Mutations
Breast cancer screening:
Learning to be aware of changes in breasts beginning at age 18
Clinical breast exam every 6–12 months beginning at age 25
Annual breast MRI or mammogram beginning at age 25
Annual breast MRI and mammogram beginning at age 30
Consider 3D mammography
Screening after age 75 should be considered on an individual basis
Breast cancer risk reduction:
Discussion of risk-reducing mastectomy
Consider medication to reduce breast cancer risk
Ovarian cancer risk management:
Risk-reducing removal of ovaries and fallopian tubes between age 35 and 40 and upon completion of child bearing.
Delaying risk-reducing removal of ovaries and fallopian tubes until age 40–45 is “reasonable” for BRCA2 mutation carriers, because the average age of ovarian cancer onset is 8–10 years later than in BRCA1 mutation carriers.
Routine ovarian cancer screening using transvaginal ultrasound and a CA-125 blood test is not recommended by guidelines but may be performed at the doctor’s discretion starting at age 30–35.
7. DailyRounds: According to the latest guidelines for the surgical management of DCIS, margins wider than 2mm were not found to be more efficacious in preventing recurrence. What do you think is an adequate margin for other breast cancers?
Dr. Kaur: Ever since breast conservation surgery was deemed safe , there has been an ongoing debate for the past few decades on what constitutes a safe margin of excision.
Recent guidelines have recommended ‘no ink on tumour’ as the standard for negative margins in BCS for invasive BC.
Meta -analysis have shown that wider (than a minimum >1 mm) negative margins do not significantly reduce LR risk.