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Comprehensive Breast Care . . . for a surgeon

Discussion in 'Surgery and Surgical Subspecialties' started by opr8n, May 7, 2008.

  1. opr8n

    opr8n 5+ Year Member

    Feb 2, 2008
    So Im doing a bunch of reading on breast right now and I have couple questions for those breast people out there (no pun intended)

    As a surgeon, do you get involved in the postoperative tamoxifen/raloxifen/gorillaoxifen/herceptin prescription or leave it up to the oncologist

    As a surgeon, do you try to stick only to the surgery and post op care

    As a surgeon, do you go over all of the benefits/risks of post op radiation and options or do you defer to the rad/onc?

    Do you reccomend lumpectomy ALONE for anyone with DCIS? (ie no radiation)

    And lastly, As a surgeon, do you consider micrometastasis positive nodes? And what treatment should those patients get? Do you do Ax dissection, radiation, chemo? I feel like this is evolving and some studdies have shed light but not everyone follows the same path, like preop bowel prep
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  3. surg

    surg 10+ Year Member

    Dec 16, 2001
    I personally do discuss all these issues with them, although I defer the final decisions to my medical and radiation oncologists and the patients to finalize. What I try to do is prepare them for what I think is likely (should) happen with them. Because of that, I do spend a lot of time at tumor boards and staying up to date to make sure that I understand the treating philosophies of those people that I generally refer to so there aren't too many surprises for the patient. I personally do not write the tamoxifen/AI prescription in general, but I wouldn't be averse to it in a patient who otherwise doesn't need anything at all (reasonably rare in my practice of reasonably large breast cancers)

    I never recommend excisional BIOPSY alone for DCIS, now lumpectomy with wide margins? Sometimes for very low grade DCIS with wide margins in elderly women, although, these days I am leaning more towards partial breast irradiation for those people as well. There is however good data that indicates that if you have nice wide margins that it is not mandatory for low VNPI scores.

    As to micromets: I think the last year has shown that the data are clear that it is a poor prognostic indicator. Personally, I still do an ALND for micromets, but not isolated tumor cells. Ax Radiation is likely to be equivalent in that case. A number of trials have attacked this. Z10/Z11 randomized people to ALND v. no further local therapy and there is a European trial that randomized them to ALND v radiation. Z10/Z11 never finished accruing, the European trial is still waiting for data to mature. So as you say, still evolving.

    WS, any thoughts?
  4. opr8n

    opr8n 5+ Year Member

    Feb 2, 2008
    bump for winged scapula
  5. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

    Apr 9, 2000
    hSDN Member
    When I see a new patient, I spend a considerable amount of time with them discussing not only the surgical managment of their disease but the medical and radiation oncology options as well. However, "getting involved" is not something I am interested in doing to the extent of prescribing SERMs or other hormonal therapy, nor do I wish to be involved in managing side/expected effects. I will write a refill for someone who has run out of their well-tolerated med and cannot get into see the med onc in due time, but that's about it.

    Like surg I feel relatively facile in knowing the indications and current uses of adjuvant therapy but I prefer to defer to the medical oncologists for such management, just as I prefer they not tell the patient what operation they need. ;) That said, I am aware of a number of surgeons who DO manage their patient's adjuvant tx.

    I see myself as part of the team of surg, med and rad oncology, +/- plastics. Therefore, I keep in close contact with everyone else on the team and have patients back to the office after their appointments with medical and radiation oncology, so we can tie everything together and I make sure that everyone is "on the same page". Unfortunately, patients often come back from medical oncology confused, not understanding the data thrown at them and why they need to be taking a medication or why they need further treatment. Thus, I spend some time re-reviewing these things with patients. Funny, but my patients tend to feel more like a "number" at the other specialists than in the surgeon's office...some stereotypes don't hold up, do they?:laugh:

    I do review the details of radiation tx, especially because I am deeply involved in partial breast irradiation and am well versed in that field. However, if they have very detailed questions (ie, fractionation schedules, etc.) I defer to my rad onc colleagues and also tell my patients that this information will be reviewed in more detail when they see the radiation oncologist.

    My practice is to also tell patients that I will not recommend breast conserving surgery if they refuse to have radiation (unless they have very limited low grade DCIS and they are VERY old and decrepit).

    Nearly 60% of patients who need radiation do not get it - either because of distance, time or fear. I cannot in good conscience recommend an operation which places them at up to a 40% recurrence rate, so I am careful to make sure they understand the role of radiation and how well it is tolerated. But I also ask my patients to report back about their experiences so I may learn and we may work toward improving the adjuvant treatment rate.

    I try and do PBI in almost all my patients, especially these little old ladies, although I am aware of the data in low grade DCIS with wide margins. Helps me sleep better at night if I know we are radiating those rogue cancer cells outside of my margins.

    Like surg, I consider micromets enough disease to do an AxND but not for focally isolated tumor cells. As I mentioned in another thread, there are mutterings of abandoning AxND for axillary radiation and the data from Europe, presented last week at ASBS, was promising. Peter Beitsch in Dallas is certainly a major proponent and runs around telling everyone "Axillary Node Dissection is DEAD!", but we'll see.

    Until the data comes out, I prefer surgical management in all but the most decrepit patients. I recently operated on a patient with a recurrence who was first treated with lumpectomy and axillary radiation (reportedly because her husband wanted to spend as little money as possible since he had a large co-pay, so preferred radiation over SLNBx. I am unsure if that was the real story. But anyway...). It was not a lot of fun going through that radiated axilla but none of her nodes were positive.

    But it is clear that not everyone follows the same path; its about a 50-50 split at ASBS.
  6. opr8n

    opr8n 5+ Year Member

    Feb 2, 2008
    thanks WS, lots of good info

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