Breast Cancers and Treatment Knowledge for the OB/GYN

Today we welcome back Dr. Edmonson for part II of our breast cancer chat. Check out last week’s post for screening and imaging information.

From a radiographically-guided core breast biopsy, there’s a lot of things that can come back. Today we’ll focus on the pathologic concerns. Dr. Edmonson breaks this down into:

Atypical Ductal Hyperplasias / Atypical Lobular Hyperplasias / Lobular Carcinoma in Situ
These lesions predict a risk for breast cancer in the future, but are not actually cancer. These are all managed surgically, with an approximately 15% upstaging rate on final pathology after excision, most pronounced with ADH. The risk models we discussed last episode can then give an updated risk of breast cancer which may alter screening strategy (i.e., if risk exceeds 20%, MRI may be used as an adjunct). Additionally, using risk-reducing medications such as tamoxifen or raloxifene may also become appropriate.

Ductal Carcinoma in Situ (DCIS)
These are non-invasive cancers which require lumpectomy or potentially mastectomy. Thereafter, radiation is usually recommended as well as risk-reducing medications such as tamoxifen or aromatase inhibitors such as anastrozole. There is a 20-30% upstaging risk at time of surgery, and additionally additional surgery may be required to get negative surgical margins as there is no reliable intraoperative technique to detect margins.

Invasive Cancers (Invasive Ductal Carcinoma or Invasive Lobular Carcinoma)
With invasive cancer, different strategies exist. Surgery versus neoadjuvant chemotherapy or endocrine therapy may be considered based on extent of disease to reduce morbidity of surgery (i.e., more limited lymph node dissection which would reduce risk of lymphedema from axillary dissection). New surgical techniques exist now as well including lymphatic reanastamosis that is helping to improve morbidity after these surgeries.

Invasive lobular carcinoma can be difficult to identify. These are less aggressive, but they often don’t show up well on imaging and are difficult pre-operatively to get good margins.

After A Diagnosis
OB/GYNs can help to reassure patients and connect them to breast surgeons. Fewer breast cancers are requiring chemotherapy, which is often a patient’s greatest fear. Surgical techniques are improving and reconstruction is widely available, including skin-sparing and nipple-sparing techniques.

Screening will be guided by the breast surgeon. This depends more and more on the individual, the pathology and tumor characteristics, and risk for local recurrence. Recall that patients on tamoxifen are at higher risk of VTE and at higher risk of endometrial hyperplasia.