Monday, August 29, 2011

Lumpectomy for Large, Lobular Breast Tumors? Treatment before surgery may make it possible

Is lumpectomy an option for breast cancer patients with large lobular tumors? According to two new studies, shrinking the tumors with chemo or hormonal therapy before surgery may allow some women to opt for a lumpectomy instead of a mastectomy.

If lumpectomy ends up being an option, how do you know if it's right for you? MD Anderson has developed an index to predict recurrence after chemotherapy followed by lumpectomy. Today we'll share a recent study on its effectiveness.

Links to all studies and a news story may be found on the breast conserving surgery (lumpectomy) page of the website.

Annals of Surgical Oncology: "Neoadjuvant Chemotherapy Increases the Rate of Breast Conservation in Lobular-Type Breast Cancer Patients"

A July Annals of Surgical Oncology study from Vienna evaluated whether neoadjuvant (before surgery) chemotherapy resulted in more lumpectomies for women with lobular breast cancer.

The study leader, Dr. Florian Fitzal was quoted by,

"Up until now it had been the view that neoadjuvant chemotherapy hardly had any benefits in cases of lobular breast cancer due to the poor response rate of the cancer, however no one had yet examined the question of the breast preservation rate."
The study found that after neoadjuvant chemotherapy, 45% of the women originally scheduled for mastectomy were able to have breast conserving surgery instead.

In addition, there was no difference in local recurrence between lobular and ductal cancers treated with breast conserving surgery, or between lobular patients treated with lumpectomy or mastectomy.

Breast Cancer Research and Treatment: "Invasive lobular carcinoma: response to neoadjuvant letrozole therapy"

Femara (letrozole) is an aromatase inhibitor used to treat hormone receptor positive breast cancer in post-menopausal women. An August 26 study in Breast Cancer Research and Treatment examined the effectiveness of Femara alone as neoadjuvant therapy in women with "estrogen receptor rich" lobular breast cancer. Women were considered for treatment if they had large operable or locally advanced breast cancer or were unfit for surgery. There was no control group. All study participants received Femara.

After 3 months of Femara, the average reduction in tumor volume was 61%, measured by ultrasound. At the time of publication, 40 of 63 patients underwent surgery, 31 of those were breast conserving surgeries. 21 patients continued with Femara alone, and 19 remained controlled at a median of 2.8 years.

The authors concluded that there is a "high rate of response" to Femara in post-menopausal women with estrogen receptor rich invasive lobular carcinoma.

The Risk of Local Recurrence After Breast Conserving Therapy in Patients Receiving Neoadjuvant Chemotherapy

Even if neoadjuvant chemotherapy can reduce tumor size, is a lumpectomy the right choice for you?

MD Anderson has developed a prognostic index to evaluate the risk of recurrence for patients treated with breast conserving surgery after neoadjuvant chemotherapy. (Link to the original study.) A score from 0 to 4 is calculated based on four factors. For each factor, a zero or one is assigned. For example,

Solitary tumors = 0; Multifocal = 1
Tumors less than or equal to 2cm = 0; Greater than 2cm = 1.
Initial lymph node status of N0 or N1 = 0; N2 or N3 = 1
Lymphovascular space invasion = 1; No invasion = 0.

The numbers are totalled to reach the prognostic index score.

An August 26 Annals of Surgical Oncology study evaluated the index in 551 patients treated from 2001 to 2005 with chemo, surgery (mastectomy or lumpectomy) and radiation. (The study does not distinguish between lobular or ductal breast cancer.)

For patients with a prognostic index score of 0, 1 or 2, the 5-year local-regional recurrence (LRR) free survival rates were similar between women treated with mastectomy and lumpectomy. However, when the score was 3 or 4, the 5-year LRR-free survival was significantly lower for patients treated with lumpectomy (69%) compared to mastectomy (93%).

The authors concluded, "The prognostic index can be used to identify patients at high risk for LRR who may be considered for more extensive surgery or enrollment into clinical trials evaluating novel strategies for local-regional control."

In addition to the prognostic index score, MD Anderson publishes several prognostic calculators to aid in the neoadjuvant chemotherapy decision process. Individual treatment decisions are based on many factors. Tools such as the prognostic index and calculators are factors to be considered, but ultimate decisions are made between a patient and her doctor.

Today's summary only highlights the most recent research on breast conserving surgery and neoadjuvant therapy. Two-years worth of news and research on every breast cancer test and treatment option may be found on the treatment pages of the website. Subscribers may create a profile based on their personal diagnosis to personalize their research.

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