Principles and guidelines for surgeons—management of symptomatic breast cancer

doi:10.1016/S0748-7983(97)80001-7

European Journal of Surgical Oncology (EJSO)

Volume 23, Issue 2, April 1997, Pages 101-109

https://doi.org/10.1016/S0748-7983(97)80001-7 Get rights and content

The European Society of Surgical Oncology is actively involved in the promotion of a high standard of surgical oncology throughout Europe. Such an ambition involves recognition of Centres of Excellence in the management of cancer patients throughout Europe. These centres have a multi-disciplinary system involved in the total care of patients with cancer and are concerned with the delivery of care to the highest available standards. It is accepted that not all patients with cancer can, nor should, necessarily be treated in such highly specialized centres. Yet all cancer patients should be guaranteed a high standard of care. High surgical standards can be ensured if surgeons treating cancer are trained in specialist centres and, when in independent practice, follow established guidelines or protocols of treatment. In common with many national surgical oncology societies, the European Society of Surgical Oncology is in the process of establishing good practice guidelines in the treatment of solid tumours. This document on the management of symptomatic breast cancer is the first of a series of guidelines to be proposed by ESSO. It draws heavily on excellent documents already in existence from the British Association of Surgical Oncology and from the Danish Breast Cancer Co-Operative Group. It is hoped that this document will be sufficiently clear and purposeful to be of help to the individual surgeon and yet sufficiently flexible to allow it to be adopted in the different medical systems throughout Europe.

References (45)

PaciE et al.
Changes in stage and treatment of breast cancer in Florence from 1985–1990
The Breast
(1994)
TubianaM et al.
Management of non-palpable and small lesions found in mass breast screening
Eur J Cancer
(1994)
CiattoS et al.
Non palpable lesions of the breast detected by mammography
AzavedoE et al.
VeronesiU et al.
Breast conservation is a safe method in patients with small cancer of the breast
SacksNPM et al.
The role of axillary dissection in operable breast cancer
The Breast
(1992)
AxelssonCK et al.
Axillary dissection of level I and ll lymph nodes is important in breast cancer classification
Eur J Cancer
(1992)
ReynoldsJV et al.
Audit of complete axillary dissection in early breast cancer
Eur J Cancer
(1994)
HollandR. et al.
Extent, distribution, and mammographic/histological correlations of breast ductal carcinoma in situ
Lancet
(1990)
SilversteinMJ
Non-invasive breast cancer

van DongenJA

Present and future state of surgical management in breast cancer

Eur J Surg

(1996)

BaumM

Breast cancer 2000 BC to 2000AD—Time for a paradigm shift?

Acta Oncol

(1993)

Eindhoven Cancer Registry

Breast cancer

EwertzM

Breast Cancer in Denmark Incidence, Risk Factors, and Characteristics of Survival

Association of the Nordic Cancer Registries

Cancer of the breast. Females

MicheliA et al.

Estimated incidence and prevalence of female breast cancer in Italian regions

Tumori

(1992)

AndreasenAH et al.

Equity and improvement in outcome of breast cancer in Denmark

EberleinTJ

Preoperative chemotherapy: where do we go from here

Ann Surg

(1995)

SaranP et al.

Multi-disciplinary breast cancer center: experience at the University of Michigan

Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom

Eur J Surg Oncol

(1995)

GillisCR et al.

Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland

Br Med J

(1996)

Blichert-ToftM et al.

Clinical trials

Sem Surg Oncol

(1996)

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Pre-operative factors indicating risk of multiple operations versus a single operation in women undergoing surgery for screen detected breast cancer
2013, Breast
Citation Excerpt :
Wide local excision is a common place in the management of breast cancer having been proven equally effective as mastectomy for the surgical treatment of localised tumours3 with identical survival rates4 and superior cosmetic results. However, failure to achieve adequate surgical margins (taken as a tumour free margin of at least 1 mm in the United Kingdom5) necessitates a re-excision or mastectomy to minimise the risk of recurrence. The intraoperative assessment of complete margin excision is crude, relying on visual and tactile assessment of the excision cavity by the operating surgeon.
We aim to identify preoperative factors at diagnosis which could predict whether women undergoing wide local excision (WLE) would require further operations. 1593 screen-detected invasive and non-invasive breast cancers were reviewed. Age, presence of ductal carcinoma in situ (DCIS), invasive cancer size on mammography, mammographic sign, tumour type, grade and confidence of the radiologist in malignancy were compared. 83%(1315/1593) of women had a WLE. Of these, 70%(919/1315) had a single operation, and 30%(396/1315) multiple operations. These included repeat WLE to clear margins (60%(238/396)), mastectomy (34%(133/396)) and axillary dissection (6%(25/396)). The presence of mammographic microcalcification, lobular carcinoma and grade 2 malignancy on core biopsy were independent risk factors for multiple operations on multivariate analysis. Women with mammographic DCIS >30 mm were 3.4 times more likely to undergo repeat surgery than those with smaller foci. The multidisciplinary team should pay particular attention to these factors when planning surgery.
Local relapse rates are falling after breast conserving surgery and systemic therapy for early breast cancer: Can radiotherapy ever be safely withheld?
2009, Radiotherapy and Oncology
Citation Excerpt :
This document addressed technical aspects of surgery, the importance of specimen orientation using sutures and clips, frozen section evaluation of margins with immediate re-excision if positive, radiographic evaluation of removal of non-palpable lesions and pathologic reporting. Following publication of national guidelines in several European countries, the European Society of Surgical Oncology issued a document in 1997 [15]. The recommendations, based mainly on British Association of Surgical Oncology and Danish Breast Cancer Co-Operative Group guidelines, focused on the importance of multidisciplinary teams with specialist expertise in breast surgery, imaging and pathology.
Rates of local tumour relapse after breast conservation treatment in women with early breast cancer are falling. Explanations for this decline are considered in this review including advances in breast cancer management and aging of the breast cancer population. Breast surgery has become more standardised following publication of practice guidelines and is mostly carried out by specialist surgeons. Systemic therapies (hormonal therapy and chemotherapy) are now more effective and are recommended to a higher proportion of patients than ever before. Radiotherapy techniques have also improved. The contributions of each factor are difficult to quantify precisely, but all are likely to be relevant. In order to identify a subgroup of women that might safely be spared radiotherapy, several factors are analysed, including the prognostic significance for local relapse of tumour characteristics (pathologic data, gene-expression profiles), patient characteristics and life expectancy (age and comorbidities).
Factors correlating with reexcision after breast-conserving therapy
2009, European Journal of Surgical Oncology
Citation Excerpt :
Eligibility for breast-conserving therapy is assessed by the breast surgeon on the basis of tumor size, the ratio of tumor size to breast size, and the location of the tumor. A tumor-free margin of at least 1 mm is considered to be safe enough for the surgical treatment of invasive breast cancer,2–4 and 5 mm for intraductal breast cancer.5 The long-term risk for local recurrences, which mostly develop in the vicinity of the initial tumor, indicates that local recurrences derive from residual tumor cells.6–10
The aim of this study was to evaluate factors affecting the risk for reexcision following breast-conserving surgery. Positive tumor margins are critical for local disease control following surgery for breast cancer. Several factors, including tumor size, multifocality, and an extensive in situ component, may be associated with a higher rate of repeat operations due to positive margins. This study included mammographic density in the analysis.
A total of 565 breast cancer patients were considered eligible for breast-conserving therapy after a core biopsy had confirmed malignancy. The patients’ mammographic findings were reviewed, and mammographic density was documented in addition to the histopathological features of the lesions. Associations between these factors and the risk for a second operation were analyzed using the chi-squared test, and a model was developed for multivariate analysis.
At least one repeat operation was necessary in 121 patients (21.4%), and mastectomy was ultimately necessary in 54 patients (9.6%). Tumor size, multifocality, and the presence of an in situ component were identified as risk factors. A mammographic density of category 4 was associated with a need for further surgery (OR 3.2; 95% CI, 1.2–11).
Mammographic density is an additional risk factor for a second operation following breast-conserving procedures, and it may make radiographic and intraoperative localization of the tumor technically difficult. Using mammographic density to define a group of patients with a higher risk of reexcision might allow these patients to benefit from more sophisticated methods of localization and margin assessment.
Selective use of post-mastectomy flap irradiation in high-risk breast cancer patients
2005, Breast
The incidence of local recurrence after mastectomy can be reduced by chest wall radiotherapy. However, only a minority of patients are at substantial risk. No UK national guidelines exist for the use of mastectomy flap radiotherapy.
This study evaluated a protocol, whereby only high-risk patients were treated with post-mastectomy flap radiotherapy; identified histologically by grade, vascular invasion and nodal status.
All women treated by simple mastectomy for invasive breast cancer at the Nottingham Breast Unit from January 1993 to December 1995 were studied ( $n = 292$ ). Postoperative flap radiotherapy was given to 147 high-risk women (50.3%). Median follow-up was 76 months. Overall, 12 women (4.1%) developed a chest wall recurrence; six were single spot recurrences and the remaining six were either multiple spot ( $n = 3$ ) or field change (field change dermal invasion, $n = 3$ ). The chest wall recurrence rate was 2.7% in those treated with radiotherapy.
A low rate of local recurrence has been achieved with selective use of mastectomy flap radiotherapy.
Guidelines to assure quality in breast cancer surgery
2005, European Journal of Surgical Oncology
The outcome of breast cancer surgery, with respect to cosmetic results, loco regional control and prognostic information from nodal staging, may vary substantially. Optimal breast cancer care starts with a proper surgical act, which can only be performed when optimal imaging and preoperative diagnosis are available. Next, on the basis of all peroperative findings, the right surgical procedure should be indicated after multidisciplinary consultation and discussion, keeping the objective of the final outcome in mind. The surgical act itself is best performed by an experienced surgeon who has maintained their experience after sufficient training. The outcome of the different procedures can be measured according to simple criteria and prospective registration. All possible surgical procedures, the indication-objectives, the training-objectives and outcome measures are described.
Quality control in breast cancer surgery
2005, European Journal of Surgical Oncology
Quality assurance is the process by which quality care can be assessed. The general principles include setting a standard with the aim of achieving particular outcomes, followed by the evaluation of parameters that allow for quality assessment. Locoregional and survival outcomes are the major parameters but require years to evaluate and have other limitations. Other parameters therefore may assist in evaluation, such as the availability of the structures and processes required to achieve desired outcomes.
Unlike chemotherapy and radiotherapy the quality of surgery is difficult to quantify, yet it is central to the issue of locoregional control and survival. In breast cancer surgery, quality control starts at the diagnostic service; from referral by the family practitioner to the appropriate triage of patients thereby preventing diagnostic delays. The surgical oncologist is pivotal in the multidisciplinary input necessary with both radiologists and pathologists in achieving the correct preoperative diagnoses of symptomatic and screen detected lesions as specified by many of the guidelines.
Quality control of the operative surgery addresses issues such as training, volume and life audit of the surgeon. Standardisation of operative technique, pathology reporting with emphasis on specimen orientation and margins, management of the axilla and how it impacts on adjuvant treatment are other important issues. More recently, the availability of breast reconstruction services and the development of the oncoplastic surgeon is becoming an important quality issue. Finally, the quality of the follow up process provides the tools to assess the outcome of both the patient and the service.

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ReviewPrinciples and guidelines for surgeons—management of symptomatic breast cancer

The Breast

Eur J Cancer

The Breast

Eur J Cancer

Eur J Cancer

Lancet

Present and future state of surgical management in breast cancer

Eur J Surg

Breast cancer 2000 BC to 2000AD—Time for a paradigm shift?

Acta Oncol

Breast cancer

Breast Cancer in Denmark Incidence, Risk Factors, and Characteristics of Survival

Cancer of the breast. Females

Estimated incidence and prevalence of female breast cancer in Italian regions

Tumori

Equity and improvement in outcome of breast cancer in Denmark

Preoperative chemotherapy: where do we go from here

Ann Surg

Multi-disciplinary breast cancer center: experience at the University of Michigan

Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom

Eur J Surg Oncol

Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland

Br Med J

Clinical trials

Sem Surg Oncol

Review
Principles and guidelines for surgeons—management of symptomatic breast cancer