Nov 17, 2013
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Can anyone give me a good source for a simple and current treatment algorithm for Stage II and Stage III invasive breast cancer treatment?

Some specific questions
What are the indications for Neo-adjuvant therapy/BCT for Stage IIb breast cancer?
Is it standard to offer this or is it safer to offer MRM?

How is Stage IIIa treated? Same as IIIb or same as IIb? Or different to both?

What are the indications for neo-adjuvant/MRN vs palliation for Stage IIIb?
How do you define success/downgrading of neo-adjuvant?

Does anyone know of a source for a current ACS or breast surgery endorsed treatment protocol?
 

FaytlND

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Isn't this kind of like asking "Can you condense a good portion of a breast fellowship into a concise, easy to digest format?" If anyone has a source, its probably WS, but it just seems like a tough request.

What's the info for? Do you have a specific case in mind? Is it for boards-related studying? Its been my impression (as with other situations) that what I'd answer on the boards is likely different than whats happening in day to any practice of high volume breast centers.
 
OP
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Nov 17, 2013
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Yes, this is for the oral boards.

Trying to understand breast surgery like a breast surgeon would be like trying to condense fellowship level knowledge into a few bite size chunks. That's not what I'm trying to do.

Having spent hours on the NCCN guidelines, I can't believe that the ABS wants people to try to do that in order to talk through a five minute scenario.

I don't really know how much dept or complexity the ABS is looking for. If I tried to work my way through a fellowship level algorithm in real time while sitting in a hotel room being grilled my head would explode.

For the boards - dealing with invasive breast cancer - I can't have the knowledge that a breast fellow would have. So where do I draw the line.

The boards prep books (How to win, passing the boards, safe answers, surgical decision making) all disagree a lot on breast.

I'm comfortable with all the procedures
Know the work up
Stage I is fairly simple (I see now that in real breast practice it's not - anyone who questions that can go consult the NCCN guidelines.)
Stage IV is fairly simple
Inflammatory is relatively simple (by simple I mean that most of the books say the same thing)

The main question is what to do with Stage II and III.
Is it necessary to have a different treatment for IIA, IIB, IIIA, IIIB, IIIC?
Or can I treat all stage III the same way I treat IBC - neo and then surgery vs. palliation based on response?

Yes, all these questions relate to the boards.

If a woman ever came to me with breast cancer I'd send her to a breast surgeon.
 

droliver

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Breast cancer does not have to be that hard, certainly for the board exam.

For board purposes I don't think you don't want to throw out neoadjuvant CRT as an answer unless there is inflammatory disease or palpable disease in the axillae. Those are the only clear cut instances where you cannot be wrong with that answer. For stages in the middle (2a-3b) the answer can vary widely between different institutions and community practices about who might get offered it as the literature has generally not shown any clinical advantage to it for these patients. The only factoid to be able to respond with if they move the scenario to say "well the patient has a large tumor and wants a lumpectomy" is to respond that neoadjuvant CRT may sometimes allow breast conservation to be performed in these cases. (BTW, this is an absolutely STUPID reason but it is talked about). The "safe answer" if they give you a larger tumor (5cm+) is to mention you would have them seen by an oncologist preoperatively for evaluation for that.

For breast cancer the things I think you want to be able to discuss briefly would include:
1) treatment of the axillae and XRT indications
2) side effects of Chemo, hormone blockers, and herceptin
3) who is safe to do nipple sparing cases on
4) how the OncotypeDX tests affects adjuvant treatment decisions (this has been the single biggest game changer in practice in the last decade)
5) work up of the nipple with bloody drainage
6) who to refer for BRCA testing
7) I think they also like to do scenarios involving whether or not you trust a b9 percutaneous biopsy or not
 

Winged Scapula

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LOL...I've had a busy week and been unable to respond until now, but I was going to say the exact same thing as droliver: the OP is making it harder than it needs to be.

Yes, NCCN guidelines are used by breast surgeons and other oncologists. However, they can be very overwhelming and difficult to wade through. I would not recommend that a GS taking the oral boards be anything but knowledgeable about their existence rather than memorizing them. The ABS does not expect anymore than that.

The main question is what to do with Stage II and III.
Is it necessary to have a different treatment for IIA, IIB, IIIA, IIIB, IIIC?
Or can I treat all stage III the same way I treat IBC - neo and then surgery vs. palliation based on response?
As droliver notes, any patient with known metastatic disease, inflammatory breast cancer or a large tumor (> 5 cm), can be referred to a medical oncologist for consideration of neoadjuvant chemotherapy (NAC). Thus, the treatment algorithm does not typically vary (for purposes of the boards) for 2A-3C. Management will depend on response (except in the case of IBC where there is no role for breast conservation). It is not necessary for purposes of the oral boards to have a different scenario for IIA, IIB, IIIA, IIIB, IIIC.

For breast some scenarios you may reasonably expect (outside of the standard breast cancer case):

1) management of bloody nipple discharge;
2) management of discordant needle biopsies
3) management of breast cancer in pregnancy
4) management of imaging abnormalities (they want to hear that you would either do or refer for a needle biopsy rather than doing an excisional biopsy)

You should be able to discuss:

1) Z-0011 and management of the axilla. Despite the lack of universal acceptance, be aware that SESAP 15 endorses this as well: breast conservation patients with positive lymph nodes are being offered axillary RT and not axillary node dissection.
2) margin width; the classic question of DCIS vs LCIS at margin, what margin you find acceptable (most say 2 mm)
3) adjuvant treatments; I do not think that you need to know details of side effects of chemotherapy. It is enough to know AC+T x 4-6 cycles, Herceptin for 1 year for Her-2/neu positive patients. You might be asked about SERMs. You should know about partial breast irradiation as a possible option after breast conservation.
4) use of Oncotype/Mammaprint/genetic testing - who are candidates for these

While I do a lot of nipple-sparing mastectomies, I don't think that has become common fodder for ABS exams as the ASBS is still in the process of collecting data for the registry. If asked and you don't know the indications, it is more than reasonable to state, "I am not comfortable performing that procedure in the face of malignancy...". Honestly, its not an operation general surgeons are doing with any regularity unless their practice is almost all breast. I cannot see the board expecting otherwise.

FWIW, I am not aware of a portable accurate resource which distills all this down. You are not alone; when I was studying for boards, the most common areas of confusion for my colleagues seemed to be breast related.
 

droliver

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I think Kimberly noted some other commonly touched on areas (diagnoses during pregnancy) and the Z-11 trial data as it relates to XRT vs traditional axillary dissection. I could imagine them trying to confuse someone who tries to discuss that with the Z-11 by getting you to try and apply it to mastectomy patients (it ONLY is applicable to lumpectomy patients at this point in time).

Kim,
I actually got off into pretty detailed discussion on both chemotherapy and XRT with complications during my orals during a breast CA scenario. I also was asked about what kind of chemo regimen and associated complications would be observed with a gastric lymphoma scenario (which I totally guessed on and got right) . I tell our residents to be able to spit out 1st line treatments for most cancers.

As an aside, I've actually taught most of the surgeons I do reconstruction with how to do NSM. It's mostly a planning of the incision thing and drawing where they need to stop. Have learned the hard way not to draw IMF incisions for this unless it's me doing the mastectomy.
 

Winged Scapula

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I didn't mean to imply that you wouldn't be asked about chemotherapeutic regimes but rather that detailed knowledge of side effects would be outside of the expectations of the ABS. I was asked as well about treatment for esophageal CA when I mentioned doing neoadjuvant but IMHO if you get into a discussion of side effects and minutiae of chemo outside of "what drugs", you've likely already passed the question (or at the very least, it isn't going to be held against you). Knowing whether chemo is an option and what's given for the most commonly asked about cancers is, of course, standard ABS fare.

As an aside (from me), what's for you happened with the IMF incisions? I prefer them for cosmetic reasons but will admit to saying a few curse words if they have a larger breast or considerable distance to the superior pole.