Breast cancer

31 July 2013

Wait-and-see approach for breast surgery

A new study suggests that women with certain breast tissue abnormalities that raise their risk for cancer can safely take a wait-and-see approach.

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Women with certain breast tissue abnormalities that raise their risk for cancer can safely take a wait-and-see approach rather than rush into surgery, a new study suggests.

Previous research into two breast conditions atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) have turned up conflicting results regarding the need for surgery, said Dr Kristen Atkins, associate professor of pathology at the University of Virginia, Charlottesville.

Both conditions indicate a non-invasive proliferation of cells in the breast. And each one raises the risk of developing breast cancer, Atkins and others agree.

But it now appears that when the patient's pathology report and the radiology report are in agreement, the lesions are unlikely to progress to cancer, according to the study, which was published online July 30 in the journal Radiology.

Women with either condition should be followed closely, the researchers said. Closer observation might involve repeat imaging every six months, or yearly mammograms with supplemental MRIs or ultrasound.

"The risk of cancer developing is not to that area [where the lesions are found]; it's to both breasts over the course of a lifetime," Atkins said.

Small risk

Some studies that tried to quantify the increased cancer risk associated with these lesions are dated. Atkins said the risk is small and translates to about a 1% per year probability of developing non-invasive ductal carcinoma in situ or invasive cancer for women with lobular carcinoma in situ, which also is called lobular intraepithelial neoplasia.

One expert welcomed the findings.

"We know we are over-treating some women [with these lesions]," said Dr Courtney Vito, an assistant clinical professor of surgical oncology and a breast surgeon at City of Hope Comprehensive Cancer Center in Duarte, California. Vito was not involved in the study.

Vito said a woman who decides to skip surgery should consult a breast surgeon, who can stratify her risks and develop a follow-up plan that takes into account family history and other risk factors.

Atkins said these lesions typically get discovered during a biopsy conducted because a radiologist has spotted something of concern on a mammogram. "We're not really sure how frequently they occur because they are usually incidental findings," Atkins said. "A biopsy is usually done for calcifications or a mass and we happen to find the ALH and LCIS."

The study of 49 women (50 cases), aged 40 to 73, looked at data from 2000 to 2010 and focused on whether the pathology report and radiology report agreed and whether cancer occurred during the follow-up period. Reports would be judged in agreement if the radiologist and the pathologist concurred on the extent of calcification and the location, for example.

Avoiding surgery

All of the women in the study had atypical lobular hyperplasia or lobular carcinoma in situ. Of the total, 43 cases were judged benign by both the pathologist and the radiologist.

Of the cases with agreement, 38 had surgical excision and five were watched closely during the follow-up. None of the 43 progressed to cancer.

In seven cases, however, the pathology and radiology reports were not in agreement. Five of those women had surgery, and two of them were found to have non-invasive cancer (ductal carcinoma in situ) when operated on. Two others were followed and did not progress to cancer.

The researchers concluded that if the reports agree, women can be monitored closely to avoid surgery, which carries a potential for disfigurement or other harm.

Vito noted that the research was done at respected centres with expert researchers. The accuracy of pathology and radiology reports is highly dependent on the expertise of the doctors involved, she said.

More information

To learn more about the risk factors for breast cancer, visit the American Cancer Society.

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Breast cancer expert

Dr Gudgeon qualified in Birmingham, England, in 1968. She has more than 40 years experience in oncology, and in 1994 she founded her practice, Cape Breast Care, where she treats benign and malignant breast cancers. Dr Boeddinghaus obtained her qualification at UCT Medical School in 1994 and her MRCP in London in 1998. She has worked extensively in the field of oncology and has a special interest in the hormonal management of breast cancer. She now works with Dr Gudgeon at Cape Breast Care. Read more.

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