Studies have concluded that women with atypical breast ductal epithelial cells have an increased relative risk of breast cancer. In a recent report by Dooley et al comparing ductal lavage to nipple aspiration, ductal lavage was proven to be safe, well tolerated and superior to nipple aspiration in collecting large numbers of epithelial cells. Most importantly, ductal lavage detected abnormal intraductal breast cells 3.2 times more often than nipple aspiration, yielding important information for patients and physicians to assess risk and decide on risk-reduction therapies. In December 2001, nearly 600 breast surgeons responded to a survey examining how women at high risk for developing breast cancer are identified and managed.

MIAMI MEETING PATTERNS OF CARE STUDY DEFINING THE ROLE OF DUCTAL LAVAGE

Previously, determining a woman’s risk was based solely on her medical history. Ductal lavage provides valuable information about the presence or absence of cellular atypia in the breast without invasive surgery. Ductal lavage is not a replacement for mammography. It is not a breast cancer detection tool. It is a risk assessment tool that can identify women at significant risk for breast cancer. The procedure is very easy to perform. It can be done quickly in an examination room without any special preparation. Patients tolerate it very well, experience minimal discomfort and report to us that they would do it again.

—Victor G Vogel, MD

Women must be counseled carefully regarding ductal lavage. Ductal lavage does not replace mammography, but it can provide additional insight into risk status. If benign cells are identified by ductal lavage, a high-risk woman remains at high risk for breast carcinoma. Long-term outcome studies will determine whether benign cytology findings on ductal lavage lower a woman’s risk of developing breast carcinoma, but this has not yet been established. Although ductal lavage has detected occult tumors in high-risk women, its sensitivity and specificity for breast cancer detection are not yet known. This fact must be weighed carefully in any decision-making process concerning surgical ductal exploration.

The management of the woman at high-risk for the development of breast carcinoma is an area of increasing clinical importance now that tamoxifen has shown to be of proven benefit, and because prophylactic mastectomy clearly decreases breast carcinoma risk in BRCA 1/2 mutation carriers. Ductal lavage offers additional information regarding risk to both women and their physicians as they ponder the complex decisions regarding hormone replacement therapy and antiestrogen risk-reduction therapy. Ongoing and future clinical studies will provide more information regarding the positive and negative predictive values of ductal lavage for breast carcinoma detection; and the reproducibility, reliability, and clinical utility of ductal lavage for tracking the progression and regression of intraepithelial neoplasia with and without the use of antiestrogen therapy.

—O’Shaughnessy JA et al. Cancer 2002:94(2):292-298.

DUCTAL LAVAGE: THE PROCEDURE 1. Gentle suction is applied to the nipple to elicit fluid. 2. Microcatheter is inserted into duct. 3. 10-20 mL of saline is slowly introduced into the milk duct in 2–4 ml increments to lavage the duct and collect epithelial cells. 4.The breast is massaged to bring fluid forward. DUCTAL LAVAGE AND CLINICAL MANAGEMENT PATHWAY   Reproduced with permission: O’Shaughnessy et al. Cancer 2002; 94 (2) 292-298.   SURGEONS If you determine a patient to be high-risk by history and/or quantitative risk assessment, do you perform ductal lavage on that patient? (Percent of physicians answering yes) 10.2% What factors determine a patient’s need for ductal lavage in your practice? Patients who request it 60% High-risk patients (by quantitative risk assessment) 53.8% Patients with breast cancer (contralateral breast) 39.3%

Dooley WC et al. Ductal lavage for detection of cellular atypia in women at high risk for breast cancer. J Natl Cancer Inst 2001;93(21):1624-32. Abstract

Dupont WD, Page DL. Risk factors for breast cancer in women with proliferative breast disease. N Engl J Med 1985;312(3):146-51. Abstract

Dupont WD et al. Breast cancer risk associated with proliferative breast disease and atypical hyperplasia. Cancer 1993;71(4):1258-65. Abstract

Fabian CJ et al. Short-term breast cancer prediction by random periareolar fine-needle aspiration cytology and the Gail risk model. J Natl Cancer Inst 2000;92(15):1217-27. Abstract

O’Shaughnessy JA et al. Ductal Lavage and the Clinical Management of Women at High Risk for Breast Carcinoma. Cancer 2002:94(2):292-298.

Wrensch MR et al. Breast cancer risk in women with abnormal cytology in nipple aspirates of breast fluid. J Natl Cancer Inst 2001;93(23):1791-8. Abstract

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